COLUMBIA  LIBRARIES  OFFSITE 

HEALTH  SCIENCES  STANDARD 


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College  of  $l)p£!ician£(  anb  burgeons 


Reference  Hibrarp 


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MEDICAL   REPORT   OF   THE 


Society  of  the  Lying-In  Hospital 


OF  THE  CITY  OF  NEW  YORK 


INCORPORATED  MARGE  1,  1799 


I^EW  YORK 
D.  APPLETON  &  COMPANY 

1897 


Press  of  J.  J.  Little  &  Co. 
Astor  Place,  New  York 


PREFACE 


In  presenting  the  following  Report,  the  Medical  Board  wishes  again  to 
call  attention  to  the  fact  that  this  Hospital  is  an  institution  the  purpose  of 
which  is  to  teach  obstetrics  quite  as  much  as  to  conduct  a  work  of  charity. 

It  has,  therefore,  seemed  proper  to  describe  at  some  length  the  methods 
of  instruction  in  use  at  the  Hospital,  and  also  the  system  of  taking  histo- 
ries and  recording  statistics. 

The  clinical  basis  of  this  Eeport  is  derived  entirely  from  the  outdoor 
service  of  the  Hospital. 

Following  the  articles  on  methods  of  instruction  is  a  statistical  synopsis 
which  covers  a  period  of  six  years,  from  the  beginning  of  the  present  sys- 
tem in  the  Midwifery  Dispensary  at  Sli  Broome  Street,  to  April  1,  1896. 

This  statistical  synopsis  includes  the  figures  in  the  two  Reports  of  the 
Midwifeiy  Dispensary  issued  in  1891  and  1892,  and  also  the  figures  of  a 
similar  s3mopsis  published  by  this  Society  in  a  medical  report  in  1893. 

There  are  also  presented  here  articles  based  upon  the  cases  in  the  ser- 
vice of  the  Hospital,  by  members  of  the  Medical  Board. 

In  addition,  articles  have  been  contributed  by  the  heads  of  the  special 
departments,  and  by  the  assistant  attending  physicians. 

Regarding  the  articles  contributed  by  ofiicers  who  are  not  members  of 
the  Medical  Board,  it  may  be  said  that  the  opinions  therein  stated  are  the 
opinions  of  the  individual  writers,  and  are  not  necessarily  endorsed  by  the 
Medical  Board.  Such  articles  have  been  more  or  less  carefully  supervised, 
but  there  has  been  no  attempt  to  influence  or  restrain  the  opinions  of  the 
authors. 

It  will  be  noted  that  there  is  no  report  from  the  OphthalmQlogist,  the 
IsTeuroloo-ist,  or  the  Dermatoloo^ist.  This  is  due  to  the  fact  that  the  mate- 
rial  at  present  collected  does  not  warrant  a  report  from  those  departments. 

In  anticipation  of  an  obvious  criticism  that  many  subjects  of  interest 
which  must  have  been  found  in  so  large  a  series  of  cases  have  not  been 
reported,  the  Board  wishes  to  say  that  these  subjects  have  been  reserved 
for  a  future  Report. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/medicalreportofsOOsoci 


CONTENTS 

PAGE 

Preface, iii 

Governors, vii 

Officers, vii 

Medical  Board, vii 

Assistant  Attending  Physicians, viii 

Special  Departments, viii 


1. 

2. 

3. 
4. 

5. 

6. 

7. 

8. 

9. 
10. 
11. 
12. 
13. 
14. 
15. 
16. 
17. 
18. 
19. 
20. 
21. 


Medical  Records  and  the  Preparation  of  Statistics, 
Practical  Instruction  Given  by  this  Hospital  to  Graduate  and 
Undergraduate  Pupils, 

Theoretical  Lectures.— Demonstrations— Recitations, 

The  Instruction  of  Nurses, 

Statistical  Synopsis,  .        .        .        .        .    H.  McM.  Painter, 

Students  of  the  Hospital, 

Statistical  Report  of  Forceps  Operations,    Austin  Flint,  Jr., 
The  Premature  Interruption  of  Pregnancy,    James  Clifton  Edgar, 


Asepsis,  Morbidity,  and  Mortality, 
Congenital  Cystic  Kidneys, 
Deformed  Pelves, 
Case  of  Cesarean  Section, 
Case  of  Alexander's  Operation, 

Version, 

Fractures  in  the  New-Born,     . 
Placenta  Previa. 


Report  of  Curator, 


Report  of  Orthop.^dic  Surgeon, 
Report  of  Embryologist, 
Report  of  Pathologist, 
Report  of  Bacteriologist, 


Samuel  W.  Lambert, 
Martha  Wollstein, 
Austin  Flint,  Jr., 
James  W.  MarJcoe, 
James  W.  Markoe, 
Austin  Flint,  Jr., 
Churchill  Carmalt, 
George  R.    WJiite, 


James  W.  Markoe  and  Martha  Wollstein, 


T.  Halsted  Myers, 
George  S.  Huntington, 
Farquhar  Ferguson, 
Martha  Wollstein,     . 


52 
65 
71 
79 
106 
108 
114 
219 
253 
258 
272 
274 
275 
283 
308 
317 
320 
324 
351 
352 


GOVERNORS. 

Egeeton  L.  Winthrop,  George  G.  Williams, 

Frederic  Bronson,  Williajvi  Greenough, 

William  A.  Duer,  F.  Delano  Weekes, 

Edmund  L.  Baylies,  Henry  A.  C.  Taylor, 

Egerton  L,  Winthrop,  Jr.,  Francis  S.  Bangs, 

Thomas  I^ewbold,  Edward  W.  Lajvibert,  M.D. 

OFFICERS. 

President. 
William    A.    Duer, 

115  Broadivay. 
Vice-President. 

George  G.  Williams, 

Chemical  National  Bank. 
Treasurer. 

Frederic  Bronson, 

76  Wall  Street. 

Secretary. 
F.  Delano  Weekes, 

58  Wall  Street. 


MEDICAL  BOARD. 

Consulting    Physicians. 

Edward  W.  Lambert,  M.D.,  William  M.  Polk,  M.D., 

Thomas  M.  Maekoe,  M.D.,  William  T.  Lusk,  M.D. 

Attending-    Physicians. 

James  W.  Maekoe,  M.D.,  H.  McM.  Painter,  M.D., 

Samuel  W.  Lambert,  M.D.,  J.  Clifton  Edgar,  M.D., 

Austin  Flint,  Jr.,  M.D. 


ASSISTANT    ATTENDING    PHYSICIANS. 

Asa  B.  Davis,  M.D.,  Geokge  R.  AVhite,  M.D., 

Churchill  Carmalt,  M.D.,  R.  C.  James,  M.D., 

^y.  E.  Studdiford,  M.D. 


SPECIAL    DEPARTMENTS. 


Orthopaedic   Surgeon. 

T.  Halsted  Myers,  M.D. 


Embryologist. 

George  S.  Huntington,  M.D. 


Neurologist. 

C.   A.  IIektkk,  M.D. 


Pathologist. 

Farquiiak  Ferguson,  M.D. 


Ophthalmologist. 

J.   L.   Adams,  M.D. 


Bacteriologist. 

Martha  Wollstein,  M.D. 


Dermatologist. 
James  Johnston,  M.D. 


Assistant   Registrar. 

Asa  B.  Davis,  M.D. 


Assistant  Curator. 

Martha  Wollstein,  M.D. 


Chief  Clerk. 

Charles  Ford. 


Chief  Nurse. 

Miss  E.  Miller. 


Assistant    Nurse. 

Miss  Margaret  M.  McCarthy. 


Registrar's    Clerk. 

Helen  F.  Nugent. 


hospital. 
Second  Avenue  and  Seventeenth  Street. 


SUB-STATION. 

Ko.  314  Broome  Street. 


DIET    KITCHEN. 

No.   rJU  JiuooMK  Strkkt. 


MEDICAL    REPORT 


OP  THE 


SOCIETY  OF  THE   LYING-IN  HOSPITAL 


MEDICAL  EECOKDS  AND  THE  PKEPARATION  OF  STATISTICS. 

SYNOPSIS. 
I.  Introduction. 

II.  The  Nature  op  the  Statistics. 

a.  Indoor  Service. 

b.  Outdoor  Service. 

c.  The  Student  Observer. 

1.  His  Inexperience. 

2.  His  Entliusiasm. 

d.  The  Checks  on  the  Student. 

1.  Fixing-  Responsibility  for  Written  Recoixls. 

2.  Written  Reports  to  Transfer  Responsibility  from  Student  to  House 

Staff. 

3.  Personal  Investigation  of  Abnormalities  by  Trained  Assistants. — 

Abnormality  Book. 

4.  Personal  Inspection  of  the  Records  at  the  Bedside  by  Trained 

Assistants. 

5.  Daily  Rotation  on  the  Postpartum  Cases. 

6.  Time-clock  Stamp. 

III.  The  Histories. 

a.  The  Blanks. 

1.  Their  Development. 

2.  The  Forms  in  Present  Use. 

X.  Medical. 

y.  Administrative  for  Students. 

z.  Administrative  for  Patients. 

b.  The  Writing  of  the  Records. 

1.  The  Student. 

2.  The  Assistant  Resident  Physician. 

3.  The  Discharge  of  Patients. 

c.  The  Checks  on  the  Histories. 

1.  The  Attendance  Book. 

2.  The  Attendance  Cards. 

3.  The  Operation  Book. 


REPORT  OF   THE   SOCIETY   OF   THE   LYING-IN   HOSPITAL. 

TV.  The  Registrar's  Office. 
a.  The  Registrar. 

1.  General  Oversig:lit. 

2.  Annual  Statistical  Report. 
h.  The  Assistiint  Registrar. 

1.  Nunihering  the  Histories. 

2.  Siunmarizing  the  Diagnoses. 
c.  The  Registrar's  Clerk. 

1.  The  Lai'ge  Statistic  Book. 

X.  Special  Arrangement. 
y.  Summarizing  Pages. 
z.  Clieck  on  this  Book. 

2.  The  Card  Index. 

u".  The  Individual  Cards. 
y.  The  Checks  on  the  Cards. 

V.  Conclusion. 


I.       iNTRODrCTION. 

It  is  the  practice  of  every  hos]ntal  to  demand  of  its  resident  medical 
staff  that  a  more  or  less  complete  medical  history  be  kept  of  eveiy  patient 
in  its  wards.  These  histories  are  bound  in  volmnes,  and  are  stored  away 
to  be  referred  to,  perhaps,  by  some  members  of  tlie  Medical  Board  who  may 
desire  to  investigate  a  special  subject,  or  to  be  produced  as  evidence  in  a 
court  of  law.  It  is  unusual,  in  this  country  at  least,  that  any  systematic 
use  should  be  made  of  the  valuable  records  thus  filed  away  every  year. 
The  Johns  Hopkins  Hospital  is  the  one  preeminent  exception  to  this  gen- 
eral rule,  and  the  reports  of  that  institution  are  unsurpassed  by  any  similar 
I'eports  pul>li.shed  in  this  country  or  abroad.  The  first  reports  recently 
published  from  the  Children's  Hospital  in  Boston,  and  the  Presbj^terian 
Hos{)ita]  in  Xew  York,  must  be  added  to  this  list. 

The  Society  of  the  Lying-in  Hospital  has  made  three  previous  publica- 
tions of  this  nature,  and  it  is  the  purjiose  of  this  article  to  present  its 
method  of  recording  its  oljservations  and  of  prei)aring  its  statistics  for  ref- 
erence and  use.  There  is  no  new  principle  involved,  but  perhaps  a  knowl- 
e<lge  of  some  working  system  may  be  of  service  to  othci's  avIio  may  desire 
to  establish  a  series  of  re])orts.  The  sy.stem  liere  developed  deals  only  Avitli 
obstetrical  cases,  and  it  is  not  complicated,  except  where  it  encounters  the 
])ossible  coni])lications  of  ))regnancy,  labor,  and  the  iMicrjx'i'al  state.  The 
neces.sary  elasticity  is  given  to  this  part  of  the  system  Ijy  the  use  of  the 
card-index  system,  so  generally  employed  in  library  catalogues. 

TT.     Thk  Natuke  ok  thk  SrATrsTics. 

The  obstetrical  service  of  the  Society  of  tlie  Lying-in  Hospital  furnishes 
two  distinct  kinds  of  statistics:  tliose  of  the  indoor  and  those  of  the  out- 
door service.     The  indoor  .service  was  estalilished  in  January,  1805,  and 


THE    MEDICAL    RECORDS   AND   THE    PREPARATION    OF   STATISTICS.  3 

consists  at  present  of  seventeen  beds.  The  histories  are  written  by  the 
resident  medical  staff,  and  are  accurate  records  of  the  observed  facts. 
This  small  plant  has  furnished  411  cases  at  the  present  time,  October  1, 
1896.  These  histories  have  been  bound  in  volumes  of  one  hundred,  and 
the  statistics  have  been  kept  separate  from  those  derived  from  the  out- 
door ser\ice. 

The  outdoor  service  was  organized  on  its  present  basis,  but  under 
another  name  (see  previous  Reports)  in  January,  1890,  and  has  furnished 
11, -492  cases  up  to  the  present  date,  October  1,  1896.  These  histories  are 
written  by  the  pupils  of  the  Hospital  from  observations  made  by  them. 
The  pupils  are  obtained  from  various  sources :  from  the  ranks  of  practising 
physicians,  from  the  undergraduate  classes  in  our  Medical  Schools,  and  from 
the  graduates  of  nurses'  training  schools.  Of  these,  the  medical  student 
forms  a  very  large  majority.  All  the  facts  demanded  by  the  history  blanks 
of  the  outdoor  service  are  recorded,  with  few  exceptions,  by  undergraduate 
medical  students. 

This  unqualified  statement  would  lead  to  a  very  erroneous  estimate  of 
the  scientific  value  of  these  statistics,  were  there  not  added  to  it  a  detailed 
account  of  the  various  checks  emplo3^ed  to  make  the  student  do  his  work 
in  a  careful  and  reliable  manner.  As  to  the  fitness  of  the  medical  student 
to  do  such  work,  it  is  the  opinion  of  the  Medical  Board  of  this  Hospital, 
that,  unassisted  and  unchecked,  his  inexperience  would  be  an  absolute  bar 
to  his  employment.  But  we  believe,  under  careful  oversight,  the  medical 
undergraduate  can  become  an  accurate  observer  and  recorder  of  facts. 
The  inability  of  medical  students  to  make  clinical  observations,  it  is 
believed  by  the  Medical  Board,  is  due  to  the  faulty  system  of  instruction  in 
our  Medical  Schools,  in  which  the  old  theoretical  lectures  still  hold  the 
prominent  place  to  the  exclusion  of  classroom  work,  and  indi^i[dual, 
clinical  instruction  of  the  student  at  the  bedside. 

This  Hospital  accepts  as  pupils  any  student,  male  or  female,  who  has 
finished  a  two  years'  course  of  study  in  any  medical  school.  Many  students 
have  received  their  first  clinical  experience  here,  and  it  must  be  said  that, 
as  a  class,  they  have  been  most  enthusiastic  in  their  desire  to  learn,  and 
energetic  in  their  work.  They  have  shown  a  feeling  of  responsibility 
toward  our  patients  which  has  insured  the  latter  a  considerate  and  careful 
treatment.  A  perusal  of  the  subsequent  articles  on  the  teaching  of  students 
will  show  how  we  prepare  the  raw  material,  and  so  instruct  the  student 
that  we  may  use  him  in  the  capacity  of  combined  nurse  and  midwife. 

A  further  study  of  the  following  sj^stem  of  checks  upon  his  work  will 
show  the  means  we  employ  to  keep  the  student  in  the  straight  path  of 
scientific  accuracy  in  spite  of  his  inexperience,  or  of  an  exceptional  desire 
of  some  individual  to  shirk. 

First. — The  responsibility  of  every  written  record  is  fixed,  by  requiring 
the  student  to  sign  his  name  to  the  patients'  histories,  to  the  records  of 
daily  visits,  and  to  every  other  written  chart  which  the  details  of  the 
service  demand  of  him. 

Second. — The  student  is  required  by  these  charts  and  blanks  to  make 


4  REPORT   OF   THE   SOCIETY   OF   THE   LYING-IN   HOSPITAL. 

written  reports,  at  least  every  two  hours,  .concerning  the  condition  of  all 
cases  of  labor  while  in  ])voiiress.  A  final  written  rojun't  of  each  case  deliv- 
ered is  tilled  out  upon  his  return  to  the  Hospital,  utul  he  must  make  an 
oral  report  of  all  ol)servations  when  he  returns  from  his  daily  ])ost])artuni 
visits.  In  these  ways  tlie  res})onsibility  for  every  observation  is  immedi- 
ately shiftetl  from  the  student  to  the  physicians  on  the  house  staff. 

T/tlr<L — "Whenever  one  of  these  reports  indicates  the  existence  of  any 
abnormal  or  unusual  condition,  one  of  the  resident  staff  of  ])hysicians  is 
sent  to  corroborate  the  unusual  occurrence  or  to  investigate  the  complica- 
tion. The  reports  of  the  house  staff  upon  these  visits  are  written  in  a  l)ook 
known  as  the  "Abnormality  Book."  These  reports  are  subsequently 
copied  into  the  daily  record  upon  the  history  chart  of  the  patient,  by  the 
office  clerk  on  night  duty. 

jFoif/'t/i. — The  students  are  visited  while  they  are  in  attendance  at  their 
cases  by  the  assistant  physicians  of  the  staff.  The  records  of  the  cases  are 
ins]iected  by  the  physicians  during  these  visits,  while  they  are  being  written, 
and  any  eri'ors  can  be  corrected. 

Fifth. — The  postpartum  cases  are  redistributed  among  the  students 
every  twenty -four  hours,  in  order  that  each  student  may  have  as  convenient 
a  route  as  possible  through  the  tenements.  This  custom  insures  also  a  cor- 
rection, by  a  more  careful  student,  of  any  possible  oversight  made  by  a 
fellow-student  on  the  previous  day. 

Sirfh. — A  time-clock  stamp  is  in  use  in  both  the  central  office  of  the 
Ilosjiital  in  Seventeenth  Street,  and  also  in  the  office  of  the  sub-station  in 
Broome  Street.  These  clocks  stamp  upon  the  original  woi'king  blanks  of 
the  Hospital  the  date,  hour,  and  minute  of  the  reception  of  the  calls, 
orders,  departure  and  return  of  students  to  and  from  cases,  etc.  In  this 
way  an  absolutely  accurate  time  record  is  kept  of  the  Hospital  business, 
and  there  is  insured  prompt  service  and  an  economical  expenditure  of  time 
on  the  i)art  of  the  student. 

HI.     Tin:    Histories. 

TIk'  Itlanks  used  for  the  recording  of  the  olDStetrical  histories  liave 
been  developed  U-om  a  study  of  similar  charts  used  in  other  institutions, 
and  fi-oin  tlic  personal  views  of  the  members  of  the  Medical  Board. 
Tlie  Hospital  owns  two  scra])-l)ooks  :  in  one  is  kept  a  sam])lc  of  every 
kind  of  stationery  that  has  been  print ('«1  U)V  its  own  use;  in  the  other, 
copies  i){  tlie  nuMlical  and  administrative  blanks  of  other  hospitals  are 
collected.  From  time  to  time  the  charts  have  l)een  revised,  ;tnd  the 
present  fonn  is  the  result  of  six  years'  use  and  experience.  The  i-egular 
Ithudis  of  the  indoor  and  outdoor  service  are  identical,  exce])t  in  size. 
The  in<loor  history  blank  is  thirteen  and  one-half  inches  Avide  by  fourteen 
;in(l  one-half  inches  long;  that  of  the  outdoor  service,  eleven  inches  wide 
by  seventeen  inches  long.  The  indoor  service  recjnires  a  tem])erature  chart 
and  a  blank  iov  bedside  notes,  which  ai'e  not  used  in  the  outdoor  service. 
The   regular   blanks   are,    a   single-sheet   "Pregnancy"    chart,   and   two 


THE    MEDICAL    RECORDS    AND   THE    PREPARATION    OF   STATISTICS.  5 

double-sheet  charts  stj^led  "Labor"  and  "Child,"  Special  blanks,  also, 
for  recording  postpartum  observations  extending  over  periods  longer  than 
ten  days,  and  also  for  special  pathological  or  operative  work,  and  a  special 
form  for  cases  of  albuminuria,  are  in  use  in  both  services.  Reproductions 
of  the  regular  blanks  and  of  the  special  albuminuria  blank  are  presented 
below;  the  others  present  no  features  not  included  in  these.  It  will  be 
noticed  that  the  charts  call  for  a  very  complete  series  of  observations  upon 
the  phenomena  of  pregnancy,  labor,  and  the  puerperium.  They  may 
seem  unnecessarily  full,  but  it  is  the  opinion  of  the  Medical  Board  that 
only  by  insisting  upon  such  minute  observations  during  the  period  of 
instruction  can  the  young  physician  be  taught  the  necessity  of  attention  to 
detail;  onlv  thus  can  the  habit  of  careful  observation  be  inculcated,  and 
only  thus  can  the  ability  to  obtain  an  accurate,  comprehensive  impression 
of  a  patient's  condition  be  acquired.  Such  a  chart  serves  also  as  a  guide 
to  the  student  in  his  outdoor  work  during  the  absence  of  his  instructor. 
The  studeut  takes  a  miniature  set  of  these  charts  to  every  case  of  labor, 
and  notes  the  required  facts  at  the  time  of  their  occurrence.  These  records 
are  subsequently  copied  upon  the  full-sized  blanks. 


6  REPORT   OF   THE   SOCIETY    OF   THE    LYIXG-IX    HOSPITAL. 

PREGNANCY. -OUT-DOOR    SERVICE. 

CONFINEMENT  No APPLICATION  No. 

SOCIETY    OF  THE    LYING-IN    HOSPITAL 

(No.  of  Cards '  OF    THE    CITY    OF    NEW    YORK, 

1  7th   Street  and   Second  Avenue, 
NEW   YORK. 


PREGNANCY. 


Name  of  Applicant,. 
Address, 


Date  of  Application iS 

Room 


House, Floor 

eld  patient, 


i'   old  patient,  \ 

\    City  Mission,  I 

»        •■       »•  J      1.  »u.«..~u         Eastern  DisKnsary,        \ 

Application  made  by through  ^    y^^  y^,,./.  25,s*,.„5l,o',   i    

i    Hebrew  Chanties,  \ 

\  previously  confined,         ] 

Birthplace, Married Single, Widow, Age, Para,. 

Diseases  of  Childhood,  {  rirst  ituilkeui) 


First  Menstruation,  {age) Character  of  Menstruation, 


rregtilar,    \ 
egi'lar, 

refuse,        ly 


sea  nly^ 

duration, 

Pain, 


Diseases  of  Puberty, . 


Husband's  History, 

Family  History 

Character  of  Previous  Pregnancies,  Labors,  Puerperiums  {miscarriages) 

(  duration,    ) 
First  Labor,  {date) Last  Labor,  (date) Last  Menstruation,  .'  date, 


quantity. 
Quickening,  {date) Condition  in  Present  Pregnancy. 

Bowels 


DATE  OF   EXPECTED  LABOR, 189... 

SUBSEQUENT    OBSERVATIONS. 


Date 


(Pathological  Examinations.) 


EXAMINATION    OF    URINE. 


Date 

Date 



Abnormality 


THE   MEDICAL   RECORDS    AND   THE    PREPARATION    OF   STATISTICS. 

A.    EXTERNAL    EXAMINATION. 

(/ace) {attitude) 


General  Appearance,- 

'HEIGHT  OF  PATIENT FT. ...IN.      WEIGHT  OF  PATIENT  ...LBS. 

{size) {sensibility) 

\(consistency) (veins) 

Mammary  Glands,  ^(siriee) (areolce) 

'  (papilla:) (nipple) 

^  (secretion) 

(form) (pigmentation) ...   


I     {striie) {umbilicus) 

Abdomen,   -<     ,    ,  ,       .      ,   .  ^,  (intermittent  \ 

I    (abdominal  fat) \tUerine  contractions ) 

\    (Jiiictztation) {abd.  ballottement) 

„    .    ,  ^  r  o  .,      •       -i  (/««a'2«.s-) (ensi/orm)     

Height  from  Symphysis  of-( 

(  (i{  inbilicus) 

(rapidity) (regularity) . 


Foetal  Heart, 

(position) (inore  than  one) . 

Foetal  Movements,  (position) (character) 

,.^      .        „  J       \  (uterine  murmur) (umbilical  murmur) . 

Uterine  Sounds,  < 

(  (other  sounds) 


Uterus,     '^''''^ ^-^"'"^ 


{position) 

{dorsal  plane) {small parts) 

Foetus,     -J  {head) (movements) 

(size) 

Circumference  of  (abdoi/ien  at  timbilicus) [pelvis) 

DISTANCE  BETWEEN  SPINES, DISTANCE  BETWEEN  CRESTS,. 

\R 

EXTERNAL  OBLIQUE,    <  TROCHANTERS, 

(From  post,  sup.  spine  of  one  side  to  ant.  sup.  spine  of  opposite  side.) 

EXTERNAL  CONJUGATE, 

Lower  Extremities,  (adema) 


B.    INTERNAL    EXAMINATION. 

J  (pigmentation) {secretion) 


External  Genitals, 

(  (veins) ...  (perineujn) 

!  (length) {size) 

Vagina,    -J  (secretion)  {temperature) 

\  (sensibility) {^nucous  inejnbrane) . 

(  (position) (size) 

Cervix,    -j  [softening) (laceration). 

'  (external  os) {internal  os) 

i  (shape) {consistency) 
(situation) (mobility) 
(presenting  part) {ballottement) 

PUBIC  ARCH DEPTH  OF  SYMPHYSIS,... 

DIAGONAL  CONJUGATE,  

TRUE  CONJUGATE 

TRANSVERSE  DIAMETER  OF  OUTLET, 

ANTERO-POSTERIOR  DIAMETER  OF  OUTLET, 

f  (specific  gravity) (reactioii) 


.%) 


\  (microscope). 
Examined  by , 


S  REPORT   OF   THE   SOCIETY    OF   THE    LYIXG-IX    HOSPITAL. 

RECORD    OF    LABOR. -OUT-DOOR    SERVICE. 
DIAGNOSIS. SOCIETY  OF"  THE  CONFINEMENT  No 

LYING=IN  HOSPITAL,   application  no 

OF    THE    CITY    OF    NEW    YORK 

1  7th  Street  and  Second  Avenue,  (No.  of  Cards ) 

NEW   YORK. 

RECORD    OF    LABOR. 

Name  ofApplicant, Date  of  Application, 189 

Address, House, Floor, Room, 

/    Old  Patient, 
\    City  Mission, 

Eastern  Dispensary, 


Application  made  by through 


^   A  «ti  York  liispensary,    1 
I   Hebrew  Chanties,  \ 

\  Previously  Confined,       ) 


Birthplace Married, Single, Widow, Age, Para,. 

Diseases  of  Childhood,  (first  walked) 


/    irregular, 
\    regu: 

First  Menstruation,  (age) Character  of  Menstruation,  -   ^'^''•'' 


egular,  \ 

regular,  j 

profuse,  I 

"\    scanty,  / 

t   duration,  V 

\  pain,  J 


Diseases  of  Puberty, . 


Family  History 

Character  of  Previous  Pregnancies,  Labors,  Puerperiums  (miscarriages) 

(  duration,    ) 
First  Labor,  ((/rt/t-) Last  Labor,  (a'a/^) Last  Menstruation,  -  rfa<<^.  t    

(  quantity,     ) 

Quickening,  (date) Condition  in  Present  Pregnancy 

(    normal,       ^ 

Month  of  Gestation, Urine,   <  ^"""""'     r   Bowels, 

\   amountf       ) 

PREPARATORY    STAGE. 

Date,  (began) 189     ,  hour M. 

Sinking  of  Uterus,  (effect  upon  abdomen) 

(upon  chest) (upon  bladder) (upon  rectum) 

Cervix,  (shortening) (secretion) 

Internal  Os,  (amount  of  dilatation) (presenting  part) 

Uterine  Contractions,  (pain  ) (frequency) 

Foetal  Heart,  (rapidity) (^regularity) (position) 

Show,   (date  of  onset) (character) (amount) 

Duration, hours minutes.         Date,  (terminated) 189     ,  hour M. 

FIRST    STAGE. 

Date,  (-Ji-^aw)  ^  "f^^^'"'^',     ,^,.         '- 189     ,   hour M. 

'  ^    *      '1  statement  of  patient,  \  ^     ' 

UTERINE    CONTRACTIONS,  (effect  on  Os) (frequency) 

FOETAL    HEART,   (rapidity) (regularity) (position) 

CERVIX,   (amount  of  dilatation) (position) 

Ciualking,  ) 
Temperature Pulse Position  of  Parturient,  <  dorsal,      V 

/  lateral,  \ 
MEMBRANES,  (intact) (spontaneous  rupture) 

(ariificial  rupture,  by  whom) VAGINAL  SECRETION, 

Vaginal  Examination*,  (made  by) (nu tuber) 

Visited  by  (attending  physician) (staff)   

Pelvi* Soft  Parti BLADDER RECTUM 

Preience  of  Attendant,  (time  of  arrival) :,.. 

PRESENTATION POSITION Diet, 

Haemorrhage,  (character) (treatment) 

Medication 


Duration hourt, minutci.         Date,  (terminated) 189    ,  hour M. 

from  beginning  of  labor.) 


THE    MEIJICAL    RFX'OKD.S    AND    THE    TRKPAKATK  ).\    OF    STATTSTICS. 
SECOND    STAGE. 

Date,   (lit'san) 189     ,   hour 

UTERINE    CONTRACTIONS,  (i-j/cci  on  progress) i^/requcncy) 

FOETAL   HEART,   (.rapidity) {regularity) (position) 

CERVIX,   {oedeinatous,  Ineerated,  incarcerated) 


Position  of  Parturient    -^f^'"'.?' 

Temperature, Pulse, ^  ^.  r  .    ,-  <  dorsal, 

at  time  of  delivery,    \  lat^-nl, 

MEMBRANES,  (intact) (spontaneous  rupture,  and  time) 

(arti/icial  rupture,  by  luhom  and  time) Vaginal  Secretion, 

Vaginal  Examinations,  {made  by) (number) 

Pelvis, Soft  Parts, Bladder, Rectum, 

Presence  of  Attendant,  {time  oj" arrival) 

Visited  by  (attendino  physician) " (staff")    

PRESENTATION, POSITION, Diet, 

Preservation  of  Perineum,  (method) 

Cord  about  Neck,   (number  0/ coils) (treatment) 

Haemorrhage,   (character) (treatment) 

Duration, hours, minutes.         Date,  (terminated) 189     ,  hour M. 


THIRD    STAGE. 

Date,   (began) i8g     ,   hour M. 

Uterine  Contractions,   (frequency) (effect  on  uterus) 

(  sitting,      ) 
Temperature, Pulse, Position  of  Parturient,  -s  dorsal. 


,  -s  dors 
(  lateral. 

Vaginal  Examinations,  {made  by) (number) 

INTRA-UTERINE  MANIPULATIONS, 

Presence  of  Attendant,   (time  0/ arrival) - . . 

Visited  by  (attending  physician) (staff) 

Haemorrhage,  (character) (treattnent) 

PLACENTAL  DELIVERY,   (time) (method) 

Uterus,   (condition) (management) 

Duration, hours, minutes.         Date,  (terminated) i8g     ,  hour. 


PERI 


(  intact,  ) 

N  E  U  M ,  -^  lacerated,       V  . 
{  operation,       ) 


HEIGHT    OF    FUNDUS    ABOVE    SYMPHYSIS. 

At  end  of  third  stage inches. 

10  minutes  after       "  "      inches. 

20  "  "  "  "      inches. 

30  "  "  "  "       inches. 

I  hour  "  "  "       inches. 

SUMMARY    OF    LABOR. 

(began,  date, hour,.    ..M.     i8g      ) 

First  Stage  1  .Duration,  hours, ...  .minutes, 

terminated,      "     "     ....M.      "       ' 

(began,  "     "     M.       "       ) 

Second  Stage-.  .■  "  "       ' 

terminated,       "     "     ....M.       "        ' 


Third  Stage  j 


(began,  "     "     M.       "       ,  ^^  ^^  ^^ 

terminated,      "     "     ....M.      "       ) 

Total  Duration  of  Labor,     "       " 

Temperature, Pulse Height  of  Fundus  above  Symphysis, inches. 

(Observed  one  hour  after  completion  of  labor.) 

Delivered  by 

Assistant 


10  RErOHT   OF   THE    SOCIErY    OF   TIIE    L^'IXG-IX    HOSPITAL. 

COMPLICATIONS,    OPERATIONS, 

Pathological  Examinations. 


SUBSEQUENT    RECORD. 


Date, 189  Day. 

I.  Countenance, 2.   Tongue, 3.   Bladder,  

4.   Bowels, 5.  Sleep, 5.   Stomach,  (Dift) 

7.   Temperature,  A.M. .  .P.M  .. .       8.    Pulse,  A.M. ..  P.M. . .       9.    Breasls,  (coiu/iiioti). .  .{secreting or  fiot). 
10.   Uterus,  {/ii-i^ht).  Acondition). .     11.   Genitals, (;////iVj) 


Lochia,  h/i(arititj) {c  ha  racier) (oi/or) 

Treatment  and  Remarks  : 


Signature, 


Datu, 189  Day. 

I.  Countenance, 2.  Tongue, 3.   Bladder,  

4.  Bowels 5.  Sleep,  6.   Stomach,  (Dii-t) 

7.   Temperature,  A.M. .  .P.M. . .       8.   Pulse,  A.M  ..  .P.M  ..  .       9.    'BTe&sX.s,  {conifition). .  .{si'<^re/i>!g^or  not) 

10.   Uterus,  Oit-ight)..{conditionj  . .     11.   Genitals, {itipples) 

la.   Lochia,  (quantity) (character) Km/nr) . 

13.  Treatment  and  Remarks  :  


Signature, 


Date 189  Day. 

I.  Countenance, 2.  Tongue, 3.   Bladder,  

4.    Bowels,  5.   Sleep 6.   Stomach,  {Dirt) 

7.   Temperature,  A.M..  .P.M. ..       8.   Pulse,  A.M  ..  .P.M  .. .       9.   Breasts,  {co/tc/it/on). .  .(sc-crc-t/nj;  or  not). 
10.  Uterus,  i/i.ig/if).  .(condition)..     11.  Genitals (.nipples) 

12.  Lochia,  (quantity) (character) (odor) 

13.  Treatment  and  Remarks  : 


Signature, 


Date, 189  Day. 

I.  Countenance a.  Tongue, 3.  Bladder,  

4.  Bowels 5.  Sleep 6.  Stomach,  (Diet) 

7.  Temperature,  A.M. ..P.M...       8.   Pulse,  A.M  ...  P.M  .. .       9.   Breasts,  (condition) ..  .(secreting  or  not). 

10.  Uterus,  l/irighl).  .(condition). .     11.   Genitals, (,nip/>l,-s) 

12.  Lochia,  (quantity) (character) (odor) 

13.  Treatment  and  Remarks  : 


Signature, 


THE    MEDICAL    RECORUS    AXD    THE    PREPAliATJuX    OF    STATISTICS.  11 

SUBSEQUENT    RECORD. 

Date, 189  Day. 

I.  Countenance, 2.   Tongue, 3.   Bladder,  

4.   Bowels, 5.  Sleep, 6.  Stomach,  (/)/V/) 

7.  Temperature,  A.M.  ..P.M. . .       8.   Pulse,  A.M.  .  .P.M. . .       9.   '&xe.2,%\.%,  (condition). .  .(secreting  oi- not) 

10.   Uterus,  {/icight) .  .{condition) . .     11.  Genitals, (nippies) 

12.  Lochia,  (quantity) (cliaractei-) (odor) 

13.  Treatment  and  Remarks  : 


Signature, 


Date, i8g  Day. 

I.   Countenance, 2.  Tongue, 3.   Bladder,   

4.  Bowels,  5.   Sleep,  6.   Stomach,  (/J'/t/) 

7.   Temperature,  A.M. .  .P.M. .  .       8.   Pulse,  A.  M  . .  .P.M  .  . .       g.   'Breasts,  (condition). .  .{secreting  or  not) 
10.   Uterus,  {height) .  .{condition)  . .     11.   Genitals, {nippies) 


12.  Lochia,  (gzinntity) {character) (odor) 

13.  Treatment  and  Remarks  :  


Signature, 


Date, 189  Day. 

1.   Countenance 2.  Tongue, 3.   Bladder,  

4.   Bowels, 5.  Sleep 6.   Stomach,  (Diet) 

7.   Temperature,  A.M..  .P.M...       8.   Pulse,  A.M  ..  .P.M  .. .       9.   BreasXs,  (condition) ..  .{secreting  or  not). 
10.  Uterus,  {/ui\^ht).  .(condition).  .     11.   Genitals, (nippies) 

12.  Lochia,  ujKantiiy) (character) (odor) ,  . . 

13.  Treatment  and  Remarks  : 


Signature, 


Date, 189  Day. 

I.   Countenance, 2.  Tongue, 3.   Bladder,  

4.   Bowels, 5.  Sleep, 6.  Stomach,  (Diet) 

7.  Temperature,  A.M. ..P.M.. .       8.   Pulse,  A.M. .  .P.M. . .       9.   'Br&asis,  (co7idition) ..  .(secreting  or  not). 
10.   Uterus,  (height),  .(condition). .     11.  Genitals, {nipples) 

12.  Lochia,  dpcantity) {character) (odo?-) 

13.  Treatment  and  Remarks  : 


Signature, 


Date 189  Day. 

I.   Countenance, 2.  Tongue, 3.   Bladder,  

4.   Bowels, 5.   Sleep 6.   Stomach,  {Diet) 

7.   Temperature,  A.M. .  .P.M. . .       8.   Pulse,  A.M. .  .P.M  .. .       9.   BTeasts,  {co7tdition) ..  .{secreting  or  not). 

10.  Uterus,  (height),  .(condition). .     II.   Genitals, (nipples) : 

12.   Lochia,  (quantity) {character) (odor) 


13.   Treatment  and  Remarks  : 


Signature, 


Date, i8g  Day. 

1.   Countenance, 2.   Tongue, 3.   Bladder,  

4.   Bowels,  5.   Sleep,  6.   Stomach,  (Diet) 

7.  Temperature,  A.M. .  .P.M. . .       8.   Pulse,  A.M  ..  .P.M  .. .       9.   Breasts,  {ccnditioti)..  .{secreting  or  not). 
10.   Uterus,  (height),  .(condition). .     II.   Genitals, (nipples) 


12.  Lochia,  {quantity) {charactet ) (odoi 

13.  Treatment  and  Remarks  :  


Signature, 


PHYSICAL    EXAMINATION    ON  DAY    AFTER    LABOR. 

Heart, Lungs Breasts, Nipples, 

Perineum, Cervix Quantity  and  character  ofLochia,    

Position,  sensitiveness  and  mobility  of  Uterus, 

Condition  of  Internal  Os, 

Parametria, Discharged 189 ,  on day  after  labor. 

Transferred 189..,  to Hospital  on day  after  labor. 

Signature, 


12 


REPORT   OF   THE   SOCIETY    OF   THE    LYING-IX    HOSPITAL. 


RECORD    OF    CHILD. -OUT-DOOR    SERVICE. 
CONFINEMENT  No APPLICATION  No 

SOCIETY    OF  THE    LYING-IN    HOSPITAL 

OF    THE    CITY    OF    NEW    YORK, 

1  7th  Street  and  Second  Avenue,  (No.  of  Cards   ) 

NEW    VORK. 


RECORD    OF    CHILD. 


Date  of  Birth, 

Name  of  Mother 

Present  Condition  of  Mother,.. 
Previous  Condition  of  Mother,. 


.  .i8g 
Address, 


Sex, , 


Para,. 


Time  of  Gestation mo. 

Caput  Succedaneum,  {location,  sizc\). . 
Cephalohaematoma,  (location,  size,). . . 

\  .  .<-vr.  / 

Labor,  -  /.  .I'l.'.is. 

{  ii!S!'UJ'untal.  ) 


Presentation, 


Position, 

Umbilical  Cord,. 


Duration, hours, minutes. 


OBSERVATION    TO    BE    MADE    AT    TIME    OF    BIRTH. 


Primary  Respirations, 


Capillary  Circulation,  -;  congested,   - 
(  anaemic,    ) 


nonitat,  \ 

at  sent.  I 

delayed.  \_ 

«     superficial.  i" 

(if  delayed.  Iio-J!  long,)  \ 

how  restored,  ] 

Temperature, 

(  Taken  ill  rcctuiit  for  five  ininuics  iiiniicdiatcly  after  Inrth.) 

TOTAL  LENGTH  OF  CHILD INCHES. 

VERTEX-COCCYGEAL  LENGTH INCHES.  WEIGHT LBS. 


PLACENTA. 

Complete, 

Shape, 

V^eight 

Size,  

Form 

Thickni;ss,   

Alterations      (appo- 
plcxy,  cysts,  etc.) 


MEMBRANES. 

Complete,  

Opening,  

Umbilical  vesicle,. 
Peculiarities, 


CORD. 

Length,  

Insertion,   

Volume, 

Peculiarities,. 


DIAMETERS    OF    CHILD. 

Occipito-mental, in. 

Occipito-frontal, in. 

Suboccipito-bregmatic, .  .  .in. 

Fronto-mental, in. 

Trachelo-bregmatic, in. 

Bi  parietal, in. 

Bitemporal,  in. 

Bimastoid, ....in. 

Bimalar, in. 

Bisacromial,  in. 

Dorso-sternal, in. 

Bistrochanteric,  in. 

Sacro-pubic, in. 


CIRCUMFERENCES 
OF    CHILD. 

Occipito-mental, 


Suboccipito-bregmatic,. 

Occipito-frontal, 

Bisacromial, 

Bistrochanteric,  in. 


GENERAL    CONDITION. 

Still  born, Macerated, 

Vernix  caseosa, Lanugo, 

Skin Anus, Genitals Subcutaneous  fat. 

Eyes, Mouth Umbilicus, 

Cry,-].,ua/e,         -  

(  absent,       ) 
Development  of  Cranial  Bones,  (sutures,  size  of  fontanelles,) 


Living, 

Development, 

Breasts, 

Noac, 

Urine,  


Sacrum,  (tirpth  of  indentation.) 

(In  plural  llrths  Irhif;  /■l.icntiu-  to  K,si,i,iit  fliysicia  n .) 


CONGENITAL    ANOMALIES. 


ATTENDED    BY. 


GENERAL    REMARKS. 


THE   MEDICAL   KECOKDS   AND   THE    PREPARATION   OF   STATISTICS. 


13 


SUBSEQUENT    RECORD. 


Cord  separated  on. . 

day 

Umbilicus  cicatrized 

on 

.  day. 

WEIGHT    OF    CHILD. 

TEMPERATURE    OF    CHILD. 

(Ta/ceii  in  rectuiu /or fi-'e  ittiinitcs.) 

LBS.    ]      OZ. 

At  birth I             i 

6th  day... 

LHS. 

OZ. 

At  birth... 

A.  M.    j    V.  M. 

1 

6th  day 

A.  M. 

p.  M. 

ist  day j 

7th  day 

1st  day 

7th  day 

2d  day , 

8th  day 

2d  day 

8th  day 

3d  day i 

gth  day. .  . 

3d  day 

gth  day 

4th  day 

loth  day 

4th  day   . . 

loth  day 

5th  day   

nth  day   . . 

5th  day.... 

nth  day 

Date, iSg  Day. 

1.  Sleep,    2.   Eyes,  3.   Nursing, 

4.  Cry,  5.   Nose, 5.  Vomiting, 

7.  Breasts, 8.   Mouth g.  Urine 

10.   Umbilicus,  {cord  off  j>tis)   11.  Skin,  {color^  eruption) 12.  Stools,  {mtinber,  color) 

13.  Genitals, 14.   Weight, ibs oz.     15.  Temperature, A.M. ..P.M. 

Remarks 


Signature, 


Date, 

I.  Sleep, 

4-  Cry, 

7.  Breasts, 

10.   Umbilicus,  {cord  off  pus) . 

13.  Genitals, 

Remarks 


2.   Eyes,  3. 

5.  Nose 6. 

8.   Mouth,  g, 

II.   SViin,  {color,  eruption)   12. 

14.   Weight, lis oz.  15. 


Day. 

Nursing, 

Vomiting, 

Urine,  

Stools,  {number,  coloj-) 

Temperature, A.M. .  .P.M. 


Signature, 


Date, 

1.  Sleep, 

4.  Cry 

7.  Breasts, 

10.   Umbilicus,  {cord  off  pus). 

13.  Genitals, 

Remarks 


2.  Eyes,  

5.  Nose, 

8.   Mouth, 

II.   Skin,  {color,  eruption) . 
14.   Weight, lbs..    . 


.Day. 

3.   Nursing, 

6.   Vomiting, 

g.   Urine, 

12.   Stools,  {number,  color) 

15.  Temperature,...   A.M. ..P.M. 


Date, 

I.  Sleep, 

4-   Cry,  

7.  Breasts, 

10.  Umbilicus,  {cord  off  pus). 

13.  Genitals, 

Remarks 


.Day. 


2.   Eyes,     

5.   Nose, 

8.  Mouth, 

II.  Skin,  {color,  eruption) . 
14.   Weight lbs..    . 


-3.   Nursing,.      

6.  Vomiting,  

g.  Urine, 

12.   Stools,  {member,  color) 

15.  Temperature, A.M. ..P.M. 


Signature, 


Date 

I.   Sleep, 

4-   Cry,  

7.    Breasts, 

10.   Umbilicus,  {cord  off  pus) . 

13.   Genitals, 

Remarks 


2.   Eyes,  

5.  Nose,  

8.  Mouth,  

II.  Skin,  (color,  eruption) 
14.  Weight, lbs 


Day. 

3.   Nursing, 

5.  Vomiting, 

g.  Urine,  

12.   Stools,  [number,  color) 

15.  Temperature, A.M. ..P.M. 


Date, 

I.   Sleep,     

4-  Cry, 

7.  Breasts, 

10.   \irc\\A\\c.'as,  {cord  off  pus). 

13.  Genitals, 

Remarks 


2.  Eyes, 

5.  Nose, 

8.   Mouth 

II.   Skin,  {color,  eruption) 
14.  Weight, lbs.. 


Day. 

3.   Nursing, 

6.   Vomiting, 

g.  Urine, 

12.    Stools,  (number,  color) 

15.  Temperature, A.M. ..P.M. 


u 


KEFORT   OF   THF:    SOCIETY    OF   TUn   LYINcMX    HOSPITAL. 


SUBSEQUENT    RECORD. 


Date, 189  Day. 

I.  Sleep,    2.   Eyes,     3.   Nursing, 

4.  Cry 5.   Nose,  6.   Vomiting, 

7.   Breasts 8.   Mouth, 9.  Urine 

10.  Umbilicus,  (r:'r(i'<>^/«j)  11.  Skin,  i< i>/<?r,  tv«///('«) 12.  Stools,  {/ill t/i/'cr,  co/or)  . 

13.  Genitals, 14.   Weight, /is <>=.     15.  Temperature, A.M.. 

Remarks 


Signature, 


Date, 

I.  Sleep, 

4-  Cry, 

7.   Breasts 

10.   Umbilicus,  ((.vri/^i^/z/i). 

13.  Genitals, 

Remarks 


.Day. 


2.   Eyes, ...       3.   Nursing, 

5.  Nose 6.  Vomiting, 

8.   Mouth 9.  Urine,  

II.   Skin,  (((VV;-,  tv-/////()«)   12.   Stools,  («;c;///'tv,  <()/(v) 

14.  Weight, //'i I'z.  15.  Temperature,..     A.M. ..P.M. 


Signature, 


Da: 


.Day. 


I.   Sleep, 

4-   Cry, 

7.   Breasts, 

10.   Umbilicus,  (iDrrt'^^/«j). 

13.  Genitals, 

Remarks 


2.   Eyes,  3.   Nursing, ...      

5.   Nose, 5.   Vomiting, 

8.    Mouth, 9.   Urine, 

II.   Skin,  (coiof,  f>tiJ>tio)i) 12.   Stools,  (iitiiiilicr,  color) 

14.  Weight, lbs o'^.  15.  Temperature,...   A.M. ..P.M. 


Signature, 


Date, 

I.  Sleep 

4-  Cry 

7.  Breasts, 

10.  M mh'xWcus,  {co7-ii  oJ/'/iis). 

13.  Genitals, 

Remarks 


189  Day. 

2.  Eyes,     3.   Nursing, 

5.   Nose, 6.  Vomiting,  

8.   Mouth, 9.   Urine, 

II.   SV.\n,  (color,  crii/'tion) 12.   Stools,  (iniiiibcr,  coloi) 

14.   Weight, ll's..   oz.     15.  Temperature, A.M. ..P.M. 


Signature, 


Dale 

1.  Sleep, 

4-  Cry 

7.   Breasts, 

10.   XJmh'xl'xcMS,  {cord  oJjT pus). 

13.  Genitals 

Remarks 


.Day. 


2.   Eyes,  3.  Nursing, 

5.   Nose,  6.  Vomiting, 

8.  Mouth, 9.   Urine, 

II.  Skin,  (color,  eruption)   12.  Stools,  (iiuiiilcr,  color) 

14.  Weight, lis (':..  15.  Temperature, A.M. ..P.M. 


Signature, 


DaU, 


.Day. 


I .   Sleep,     

4-  Cry 

7.   Breasts, 

10.   Umbilicus,  (f(»»-//<j^/»//). 

13.  Genitals, ..   . 

Remarks 


2.   Eyes, 3.   Nursing, 

5.   Nose 6.   Vomiting, 

8.   Mouth,  g.   Urine, 

II.   Skin,  {<  olor,  criiplioii) 12.   Stools,  (iiiiiiibcr,  color) 

14.  Weight, lbs o:;.     15.  Temperature, A.M. 


Signature, 


Date, 

I.  Sleep,  ...    

4-  Cry,     

7.  Breasts 

10.   Umbitlcut,  (cord off  Jiui). 

13.  Genitals, 

Remarks 


.Day. 


2.   Eyes,  3.  Nursing,.    ... 

5.  Nose, 6.  Vomiting,  .... 

8.   Mouth g.   Urine, 

II.  S\i'\n,  (color,  eruption) 12.  Stools,  (;/;/«//'(■ 

14.  Weight lbs oz.  15.  Temperature,. 


color) 
.A.M. 


.P.M. 


Signature, 


THE    MEDICAL   RECOKDS   AND    THE    PKEPARATIOX    OF   STATISTICS.  15 

SUBSEQUENT    RECORD. 

Date, 189  Day. 

I.  Sleep,    2.  Eyes,  3.   Nursing, 

4.   Cry,  5.   Nose,  6.   Vomiting, 

7.   Breasts, 8.   Mouth, 9.   Urine, 

10.   'Umhi\icus,  {cvr,/  off" /ii/s)   II.  Skin,  (c'o/or,  i'ru///i>/i) 12.   Stools,  (im/uic-r,  co/ar) 

13.  Genitals, 14.  Weight, Ihs.... oz.     15.  Temperature,   ...  A.M ..  .P.M. 

Remarks 


Signature, 


Date, 189  Day. 

I.  Sleep, ..    .       2.   Eyes,  3.  Nursing, 

4.   Cry, 5.   Nose, 5.  Vomiting, 

7.   Breasts, 8.   Mouth, 9.  Urine,  

10.   \i mhiWcMS,  (cord  off /> us) 11.   SVXn,  {color,  crtiptioii)   12.  S\,oo\%,  (number,  color) 

13.  Genitals, 14.  Weight, lbs oz.     15.  Temperature, A.M. ..P.M. 


Remarks. 


Signature, 


Date, i8g  Day. 

I.   Sleep, 2.   Eyes,  3.   Nursing, 

4.   Cry, 5.  Nose, 5.  Vomiting, 

7.   Breasts, 8.   Mouth, 9.   Urine, 

10.   MmhWizMS,  (cord  off  J>us) 11.   Skin,  (color,  eruption) 32.  Stools,  (innnbcr,  color) 

13.   Genitals, 14.   Weight, lbs 0:.     15.  Temperature,.  . .   A.M. .  .P.M. 


Remarks. 


Signature, 


Date, 189  Day. 

I.   Sleep, 2.   Eyes,     3.   Nursing, 

4.   Cry 5.  Nose, 6.  Vomiting,  

7.   Breasts, 8.   Mouth,   g.   Urine, 

10.   Umbilicus,  (<:();-</ c_^/«i-) II.  Skin,  (coloj-,  eruptio?i) 12.  Stools,  (nu7nbcr,  color) 

13.   Genitals, 14.  Weight, lbs oz.     15.  Temperature, A.M. ..P.M. 


Remarks. 


Siarnature, 


Date, 189 Day. 

I.   Sleep, 2.   Eyes,  3.   Nursing, 

4.   Cry,  5.   Nose,  6.  Vomiting, 

7.    Breasts, 8.   Mouth,  9.  Urine, 

TO.   Umbilicus,  (cord  off /> us) 11.  Skin,  (color,  eruJ>tio)i) 12.  Stools,  (number,  coloi-)  . 

13.  Genitals, 14.  Weight, lbs oz.     15.  Temperature A.M.. 

Remarks,  r 


Signature, 


Date, 189  Day. 

I.  Sleep,     ...       2.   Eyes, 3-   Nursing, 

4.   Cry, 5.  Nose 6.  Vomiting, 

7.   Breasts, 8.   Mouth,  9-  Urine, 

10.   \Jmhilicus,  (cord  off  pus) 11.   Skin,  (color,  eriipiion) 12.    Stools,  (nmnber,  color) 

13.   Genitals, 14.  Weight, lbs.. oz.     15.  Temperature, A.M. 

Remarks 


Signature, 


PHYSICAL    EXAMINATION    ON  DAY    AFTER    LABOR. 


Nose, Mouth,  Skin, 

Umbilicus, W^eight, 


Discharged 189 ,  on day  after  labor. 

Transferred  to Hospital  on day  after  labor. 

Signature, 


IG    ~  REPORT   OF   THE   SOCIETY    OP'   THE    LVING-IN    HOSPITAL. 

ALBUMINURIA. -OUT-DOOR    SERVICE. 
CONFINEMENT   No APPLICATION  No 

BLANK    FOR    ALBUMINURIA. 

PREVIOUS    RENAL    HISTORY 

With  especial  reference  to  presence  and  duration  oT  any  of  following  symptoms 
(If  any  of  these  date  from  present  pregnancy,  state  from   which   month.) 

Dropsy 

Quantity  of  Urine,   i/arg-,-  or  swall) 

Bloody  Urine 

Albuminuria, 

Pain  over  Kidneys, , 

Habitual  Condition  of  Skin,   (/rt-e  or  scatity  J>crsf>iratio>i) 

Headache,   {frontal,  veriicah  occipital) 

Failure  of  Vision, 

Vomiting  or  Diarrhoea,    

Anorexia 

Marked  Anaemia, 

Convulsions,  Stupor  or  Coma, 

Mental    Symptoms 

History  of  any  Infectious  Disease,  \  f^"  '^r^'i/^.'''),  '''■^^"'^''r  rheumatism,  \  ^^^  ^^  ^\^o^o\ 

•'  •'  '  \  tyhoid,  syphtltSypneunioma,  phthisis,  )  ' 

PRESENT    RENAL    HISTORY 


Dropsy,   (distribution,  degree) 

Pain  over  Kidneys, 

Headache,   {position,  degree,  time  of  day  when  most  marked). 


Impairment  of  Vision,   t,/ei;ree,  rapidity  o/ development;  one  or  both  eyes;  retinitis). 


Vomiting,   Diarrhoea,   Anorexia, 

Anaemia 

Pulse,    i  frequency,  regularity,  large  or  small,  tension.     Is  Tessel  thickened ?). 


Heart.   \  "f-  'if'l/hyP'rtrophy  or  dilatation  or  both,  I       ,     ^  distinctly  feeble 

{  accentuation  of  aortic  or  pulmonic  id  sound .     (  ■' 


LungB,   (<•//.  expansion,  signs  of  consolitialion  or  of  emphysema  or  of  oedema)  . 


Convulaions  :     Time  of  ist  Seizure,  {month  of  pregnancy,  stage  of  labor,  post  part  um) .    .. 

Frequency  of  Seizures Length  of  Seizures  and  Duration  of  Intervals, 


Seat  of  Commencement Mode  of  Spreading,. 


THE    MEDICAL    KECORDS    AND   THE    PREPARATION'    OF    STATISTICS.  17 


ALBUMINURIA. 


Convulsions  ^Cont.),  Deviation  of  Head  or  Eyes, 

Usual   Position   of  Arms, 

Paralysis,   {one-sided  or  bilateral ) 

Rigidity,   [local  or  general ) 

Fibrillary  Twitching  during  Intervals,   ('Mhere  located) 

Reflexes  {esp.  knce-jcrks).     Are  they  obtainable  during  Intervals? 

Condition  of  Pulse,  Temperature  and  Respiration  during  and  after  Seizures,. 


Pupils,  size,  reaction  to  light. 


Coma,  Duration  and  Onset, 

Can  Patient  be  Roused  ? 

Pupils,  size,  equality,  reaction  to  light,  reaction  on  pinching  skin  of  neck,. 


Mental  Symptoms,   (csp.  maniacal  excitement'). 


Treatment  of  Convulsions, (<5/tv^//«^,  transfusion^  saline enema^  mo7-J>/iine,  veratrum^  7iitro-glycerine,  chloral). 


Effect  of  Treatment  on  Pulse,  Temperature,  Respiration,  Convulsions,  Coma,  Urine,. 


URINARY    EXAMINATION. 


Date  of 
Examination 

Vol- 
ume in 

24 
Hours 

Sp.  Gr. 

*Albumen, 

( Trace.,  Moderate., 
Abundant) 

Albumen, 

•Quantity  by 

Esbach 

Casts,   Kind. 

[Few  or  Many) 

Blood,  Pus  or 
other  Sediment 

1 

■  Use  folio-wing-  tests— (x)  Heat  and  Nitric  Acid.     (2)   Cold  Nitric  Acid  {ring  test). 


18  REPORT   OF   THE   SOCIETY    OF   THE    LYING-IN    HOSPITAL. 

The  practical  ajiplication  of  the  various  checks  on  the  student,  used  in 
the  outdoor  service,  requires  a  set  of  blanks  which  may  be  called  "  Adminis- 
trative Blanks  for  Students."  The  frequent  reports  sent  by  the  student 
from  his  labor  cases  are  always  made  upon  th<?  following-  printed  form, 
which  must  be  tilled  out  in  detail  each  time,  without  regard  to  previous 
re})orts  from  the  same  case  : 

SOCIETY   OF    THE   LYIXG-IK    HOSPITAL    OF    THE   CITY   OF 

XEW   YORK, 

251  East  ITtu  St.,  New  York  City. 


"When  sending  to  the  Hospital  for  assistance,  students  must  in  all  cases 

use  and  fill  out  this  blank. 


New  York, o'clock, M. 

Patient's  Kame, 

Address, 

House, Floor, Room, 

Number  of  Pregnancy, 

Month  of  Gestation, 

Duration  of  1st  Stage, 

"  2d     " 


Foetus 

by  abdominal 

palpation. 


Pulse, Temp. , 

Foetal  Heart  (frequency), position,.. 

Dorsal  plane, 

Head,  

Small  parts, 

^  Movements, 

Presentation, Position, 

Os  uteri  (size), condition, 

Memljranes,  

'  Above  brim, 

r>         ,.•  _4.       En'^ag'cd, 

Presentmg  part,  -'    .  , 

On  Perineum, : 

('li;ir;uti  r  :iii(l  trc(juency  of  labor  pains, 


(iencijil  (  onditions  and  remarks: 


Attendant. 


THE    MEDICAL    RECORDS    AND   THE    PREPARATION    OF   STATISTICS.  1'.) 

We  insert  next  a  page  from  the  "Attendance  Book."  Each  page  of 
this  book  is  devoted  to  a  single  case,  and  it  is  filled  out  by  the  student 
immediately  upon  his  return  from  the  completion  of  his  case: 


SOCIETY  OF  THE  LYING-IN  HOSPITAL 


OF    THE    CITY    OF    NEW    YORK, 


SECOND  AVENUE  AND  17th  STREET,  N.  Y. 


Application  JVb Bag  Jfo Confinement  J^o 

Arrival  at  Case 189 (Time) a.  p.  m. 

JVame 

Address House Floor Room 

Month  of  Gestation Presentation Position 

Child  delivered  at a.  p.  m 189 

Placenta  delivered  at a.  p.  m 189 

Returned  to  Hospital  at a,  p.  m.  189 

Operation :. 


Delivered  hy 


Attending  Physician. 

Staff 

Pupils 

Operator 

Staff 


Assistants 

Pupils. 

RemarTcs 


20 


REPORT   OF   THE   SOCIETY   OF   THE    LYING-IN   HOSPITAL. 


The  oral  re])orts  of  the  students,  concerning  the  daily  condition  of  the 
postpartum  cases,  are  made  from  notes  written  at  the  bedside.  These 
reports  are  received  by  the  resident  physician  or  his  representative,  and 
are  written  bv  him  on  a  slate,  arranged  in  the  following  manner: 


Headings  of  PosTPARTU>r  Slate. 


•A 

LOCATION 

IX    TENEMENT    HOUSE. 

o 

9 

f3 

u 

^ 

Co 

+3 

< 

or  Ke 
ding. 

1— < 

o 

f3 
o  XT' 

rA 

3 
m 

j2 
.2 

c"3 

o 

o 

liight 
Doo 

II 

B^ 

This  slate  serves  as  an  index  to  postpartum  complications  Avhich  require 
subsequent  investigation  by  the  house  staff.  The  assistant  resident  physi- 
cians record  the  result  of  their  investigations  of  such  com})lications  in  a 
l>lank  book  called  the  "  Abnormality  Book." 

The  subsequent  transcription  of  these  records  and  the  use  by  the 
student  of  the  small  ro])rints  of  tlie  medical  histories  at  the  bedside  have 
been  alrea<ly  described. 

Both  the  outdoor  and  the  indoor  services  require  a  set  of  "  Adminis- 
tnition  Blanks  for  Patients."  These  blanks  serve  to  keep  a  reliable  record 
of  tlie  patients  and  their  respective  histories.  Each  set  of  blanks  is  a 
<Uq)licate  of  tlie  otlier,  although  slight  differences  in  detail  will  Ix'  noted  in 
tlio  following /y'-v^////!-,'.  An  "  A])i)lication  ]>ook  "  is  Iccpt,  in  \vliich  every 
applicant  for  treatment  is  recorded,  and  given  a  nmiilx^r  in  secpKnice  of 
a])plicalion,  known  as  the  "Application  Nund^er." 

TIm'  antepartum  cases  arc  known  by  their  aj)})lication  number,  until 
after  theii-  lielivej-y.  when  they  receive  a  second,  or  "  ("onlinenient  A'um- 
Ijer."  The  apjtlicatioii  iiuinbei-  also  serves,  at  tlie  liinc  of  delivery,  to 
tnice  the  |»re<rnancy  cliai-l  which  has  be(.'n  on  fih^  since  tlu;  (lat(i  of  applica- 
lirm.     Tlnse  apj)li<;atiou  hooks  are  posted  daily  by  the  ollice  clerk. 


THE  mp:dical  records  and  thk  preparation  of  statistics. 


21 


Headings  of  Indoor  Service  Application  Book. 


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t 

© 

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r-i 

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t>. 

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Headings  of  Outdoor  Service  Application  Book. 


fH 

^ 

® 

o 

,£2 

© 

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,J^ 

r-i 

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t=^ 

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« 

A  card  bearing  the  address  of  the  Hospital,  the  name  and  address  of 
the  patient,  and  her  application  number,  is  given  to  every  woman  at  the 
time  of  her  application.  These  cards  are  to  be  returned  to  the  Hospital 
whenever  the  patient  needs  attendance.  The}^  serve  as  an  index  to  the 
application  numbers,  and  insure  the  selection  of  the  proper  history  blank. 
A  record  of  the  progress  of  the  outdoor  labors  is  kept  on  the  three  blanli 
spaces  on  the  face  of  the  cards,  by  the  use  of  the  time-clock  stamp.  All 
the  cards  of  j^atients  in  labor  are  kept  on  a  reference  file  on  the  office  desk. 
The  obverse  and  reverse  of  these  cards  are  reproduced  here :  the  reverse  is 
Avholly  for  the  information  of  the  patient.  The  different  districts  of  the 
city  are  designated  by  varying  the  color  of  the  card. 


22  REPORT   OF   THE   SOCIETY    OF   THE    LYING-IN    HOSPITAL. 

Patient's  Cakd  fok  Indoor  Service. 

Society   of  the    Lying=ln    Hospital, 

SECOND    AVENUE   AND    17th    STREET, 

New  York  City. 


Krrlicktion    Ckrd. 

Application  JVo Date 189 

JVuDIP  '. 

Address House Floor Eoovi 

Return  with  this  card  for  admission  to  Hospital 

189 

//  taken  with  labor  pains  before  above  date,  come  to  Hospital  at  once, 
bringing  this  card  luith  you. 

(SEE  OTHER  SIDE) 


PATIENTS  COMING  TO  HOSPITAL  FOR  ADMISSION  SHOULD  BRING 
WITH  THEM  A  SET  OF  BABY  CLOTHES. 

Application    for    admission     to    Hospital     for     care    in     childbed 
should    be    made    between    the    hours    of    i    and    2    P.   M. 
Emergency  cases    will    receive    attention    at    any    time. 

IF  NECESSARY  AN  AMBULANCE  WILL  BE  FURNISHED  TO  BRING 
PATIENTS  TO  THE  HOSPITAL 

Visitors  will  not  be  allowed  to  see  patients,  but  ina\'  inrjuirc 
about  them  as  often  as  they  desire. 

Women  without  homes  will  be  referred  to  some  suitable 
charitable    institution    upon    leaving    the    Ilfxspital. 


THE    MEDICAL   RECORDS   AND   THE   PREPARATION   OF   STATISTICS.  23 


Patient's  Cakd  for  Outdoor  Service — Main  Hospital. 


Date 189 


A.  JV'.. 


SOCIETY   OF  THE 

Lyinq=In  Hospital, 


« 


2d  Ave.  &  ITthi  St., 

NEW    YORK    CITY. 

JSfame 

Address House Moor Boom.,. 


(SEE  OTHER  SIDE) 


Free  medical  attendance  in  childbed  will  be  furnished  at  their  homes 
to  women  who  are  unable  to  pay  for  such  services. 

Applications  for  attendance  should  be  made  at  the  HOSPITAL,  2nd 
AVENUE  &    17th    STREET,   between   the    hours    of    I    and   2    P.    M. 

Emergency  cases  will    receive   attention   at  any  time. 


In  casi  di  parto,  si  prestano  gratuitamente  cure  mediche  at  domi- 
cilio  delle  parturienti,  quando  questo  siano  povere  e  non  abbiano  i 
mezzi    per    pagani. 

Le  richieste  per  attenere  queste  cure  gratuite  devono  essere  fatte 
al  OSPEDALE,  2da  AVENUE  e  STRADA  17,  nelle  ore  prescritte  cive 
dalle    I    alle   2   P.  M. 

Nei   casi   urgenti   si    provederei    immediatamente   a   qualunque  or^a. 


Unentgelbltd^e  (irstltcfte  3Sefianbtnng  tion  2Bocf)nerinuen  ober  graiim,  treldje  ibre 
'Jfieberfunft  erwarten,  fallg  fie  iud;t  fiir  bte  SSe^anbluug  jablen  fi5nnen. 

Tim  melbe  fidj  im  §of»)ital,  2.  ^be.  unti  IT.  Stc,  i\v\\&)Q\\  1  unb  2 
U&r  9?ac^mtttag§. 

Sringeitbe  gcitte  icerben  ju  jeber  ^fit  be^anbelt. 


^n^-it3D  yni7  nj'-x  rjyiiy  yn3  ^xto^siDxn  j\s  \vhv^:)  Tin  'i?^^  |yo 
•lyn^yo  :3"^  nyny^  iv  T]n  lyo  \v?  '\r]i^^Vi^  ly^^nj  x  px  |yn 


•H 


REl'OKT   OF   THE   SOCIETY    OF   THE   LYING-IN    IIOSPJTAL. 


AVhen  a  patient  is  admitted  to  the  indoor  service,  the  following-  admission 
blank  is  tilled  out  and  ke})t  on  tile  in  the  office.  The  admission  card,  also 
])resented  below,  is  projierly  tilled  out  and  is  sent  to  the  wards  with  the 
]>atient.  The  reverse  of  the  card  is  wi-itten  when  the  child  is  born.  The 
facts  recordetl  on  these  two  blanks  enable  the  Kesident  Physician  to  fill  out 
the  birth  certificate  or  other  blanks  required  by  the  City  Bureau  of  Yital 
Statistics. 


SQGielY  0f  the  liYing-ln  Hsspital, 

Second  Avenue  and  17th  Street, 

NEW  YORK  CITY. 


ADMISSION     BLANK 


On  .lihnis.sitm,  Stiniiji  ii'itii  Time  Clock, 


Name . 


How  admitted 

Address  House Floor Room 

Age Color.. Single  — Married — Widow. 

Occupation Birthplace 

How  long  in  U.  S In  City   

Father's  name Birthplace 

Mother's  name Birthplace 

Friend's  name 


Address  

Number  of  previous  children Number  now  living. 

Father  of  child,  name 

Age   Address 

Birthplace   Occupation 

Remarks 


Stamp  taith  Time  Clock  here. 


^JHE   MEDICAL   EECORDS  AND   THE   PREPARATION   OF   STATISTICS.  25 

SOCIETY  OF  THE  LYING-IN  HOSPITAL 

2d  AVENUE  &.  17th  ST.,  NEW  YORK  CITY. 
CARD  OF  ADMISSION  TO  WARD. 

Application  No Confinement  No. 

Admit 

to  Ward 

Date  of  Admission i8g 

Diagnosis 

Date  of  Discharge 1 89 

Cause  of  Discharge 

- M.  D. 

(SEE  OTHER   SIDE) 


CHILD. 


Date  of  Birth 

Name 

Sex Color. 

Presentation 

Position 

Period  of  Gestation 

Operation 


Confined  by. 


The  office  clerk  copies  from  the  attendance  book,  which  is  filled  out  by 
the  student,  the  facts  demanded  by  the  ' '  Attendance  Cards. ' '  These  cards 
contain  fifty  lines,  and  the  cases  are  entered  in  the  order  of  their  confine- 
ment. Cards  are  used  to  duplicate  this  part  of  the  attendance  book, 
because  they  are  more  compact,  and  the  different  pages  of  the  attendance 
book  must  often  be  used  by  various  officers  and  clerks  at  the  same  time ;  a 


26 


REPORT   OF   THK    SOCIETY    OF   THE    LYING-IN    HOSPITAL. 


book  does  not  permit  this  eas}'  reference.  These  cards  form  an  index  to 
the  confinement  numbers  of  tlie  cases,  and  to  the  histories.  The  same 
form  of  card  is  used  to  record  the  cases  in  both  services. 


Headings  from  the  Attendance  Cards. 


rt 

o 

;-i 

§3 

fl 

0) 

rO 

C 

o 

d 

2 

o 

:^ 

O 

11 

a* 

o 

g 

Ph 

02 

o 

(-1 

6 

03 

1:3 

o 
d 

03 

o 

50 

.o 

0) 

c 
d 

5; 
d 

d 

^ 

c5 

^^ 

ce 

13 

•l-H 

•r-( 

o 

o 

o 

® 

^ 

ft 

< 

^ 

<1 

ft 

P 

^ 

O 

O 

P^ 

The  Resident  Phj'sician  writes  a  brief  resume  of  all  operations  done  by 
any  members  of  the  medical  staff,  or  by  one  of  the  Attending  Physicians, 
in  a  special  book,  the  "  Operation  Book." 

Headings  of  Operation  Book. 


ANiESTHETlO. 

s 

-t-j 

. 

^ 

^ 

Oi 

a 

d 

o 

B 

-t-i 
'^   bb 

^ 

■s 

'Sg 

^ 

d 

® 

M 

r^ 

d 

. 

dft 

•43 

o 

i 

d 

O 

.2 

'+3 

o 

d 
o 

.2  ^ 

^ 

-^ 

s 

g 

§D 

CD 

be 

"^     r^ 

8i 

c3 
S 

a 

o 

•  ^ 

sx 

2- 

u 

d 

d 

o  ^ 

d 

(D 

O 

O 

O 

p— 1 

O 

o 

P 

O* 

ft 

Q 

-< 

Ph 

The  following'-  l)l:nil<  is  used  to  record  any  coiiiplicjition  discovered 
among  the  ant<'partuni  ap[)li(:ants.  Tliese  "  Abnoi-inality  lilanks  "  for  the 
cases  of  both  services  are  made  out  by  the  Assistant  llesident  Physicians, 
and  Jire  kejit  on  a  roforoncc  file  in  th(;  ()ffic<\    Hioy  arc  c-arofully  scrutinized 


THE    MEDICAL    RECORDS   AND   THE    PREPARATION   OF   STATISTICS.  27 

by  eacli  Attending-  Ph3^sician  immediately  upon  assuming  control  of  the 
Hospital,  in  order  that  he  may  have  in  mind  any  abnormal  cases  falling 
due  during  his  service. 

ABNORMALBTY    BLANK. 

Application  J^o Date, 189 

J^ame, Para, 

Address, House, Floor, Room 

DATE  OF  EXPECTED  LABOR, 189 

History  of  Previous  Labors 

MENSURATION. 

Between  Spince, Right  Oblique, Depth  of  Symphysis, 

Betiueen  Cristce, Left  Oblique, Pubic  Arch, 

Conjugata  Externa COjYJ.  DIAGOJfALIS, COMJ.  VERA, 

Transverse  of  Outlet, Antero- Posterior  of  Outlet, 


URINANALYSIS. 

Specific  Gravity, Reaction,. 

Sugar, Urea, 

Albumen, 

Microscope, 


REMARKS. 


Exainined  in  Service  of Attending  Physician 

Examined  by 

DATE. 

SUBSEQUENT   OBSERVATIONS. 

The  student's  first  duty  upon  returning  to  the  Hospital  after  an}-  service, 
is  to  report  to  the  Resident  House  Physician  or  his  representative.  After 
making  this  report,  he  must  record  upon  the  History  Charts  the  observa- 


28  REPORT   OF   THE   SOCIETV    OF   THE    LYING-IX    HOSPITAL. 

tions  be  has  made,  and  attach  his  signature  thereto.  These  records  are 
inspected  each  evening  by  one  of  the  Assistant  Resident  Physicians,  for  the 
])ur]X)se  of  detecting  anil  correcting  inconsistencies  and  errors.  AVhen  a 
cjise  lias  been  discharged,  and  the  history  has  been  signed  by  the  Resident 
riiysician.  it  is  turned  over  to  the  Registrar's  office. 

Tlie  checks  on  the  loss  or  disa.p])ea.rance  of  any  history  are  furnished  by 
a  reference  to  the  attendance  book  or  to  the  attendance  cards.  The  check 
on  the  c<)ni])leteness  of  a  history  is  furnished  by  a  comparison  with  the 
attendance  book  and  with  the  oi)eration  book. 

lY.     The  Registrar's  Office. 

This  department  is  a  feature  in  hospital  organization  which,  as  far 
as  we  know,  is  a  new  departure.  There  are  three  workers  in  the 
Registrar's  department  of  this  Hospital.  They  care  for  the  cards,  attend 
to  the  binding  of  the  histories,  and  prepare  the  statistics  for  reference 
and  pul)lication.  The  Registrar  is  a  member  of  the  Medical  Board,  and 
holds  office  for  one  year;  he  oversees  the  work  of  the  Assistant  Registrar 
and  of  the  Registrar's  clerk.  The  five  Attending  Physicians  rotate  in 
order  in  this  duty.  Each  Registrar  makes  to  the  Medical  Board  a  complete 
statistical  report  on  the  cases  observed  during  his  year  of  service.  The 
Medical  Board  subsequently  publishes  these  rej)orts  singly  or  in  various 
combinations,  as  seems  advisable.  The  Assistant  Registrar  is  also  one 
of  the  xVssistant  Attending  Physicians.  It  is  the  duty  of  this  officer  to 
number  the  histories  from  the  attendance  cards ;  to  discover  all  the  points 
of  interest  in  each  history,  and  to  summarize  these  at  the  upper  left-hand 
cornel*  of  the  Record  of  Labor  C^hart  under  "  Diagnosis. "  He  also  indicates 
in  the  upper  right-hand  corner  of  tlie  same  cluirt  the  numbei'  of  cards 
required  for  each  history.  (This  will  be  explained  later  on,  undei-  the 
sul)ject  of  the  Card  Index.)  The  manual  labor  of  com])iling  the  statistics 
devolves  U])on  the  Registrar's  clerk,  who  is  a  ])ermanenf  employee  of  the 
IIos])ital. 

The  statistical  material  divides  itself  easily  into  two  main  classes: 
Fi/'xt.  Those  facts  which  are  common  to  all  the  histories,  and  relate  to  the 
nornud  processes  of  pregnancy,  labor,  and  the  puerperium.  Second.  The 
facts  which  vary  in  each  history  and  whicli  comprise  the  complications  and 
abnormalities  of  an  obstetrical  service. 

Tin:  Ijiiuje  Siathttc  Booh. — The  first  set  of  facts  are  recorded  in  iai-ge 
lK>oks  arrangerl  so  that  each  history  occupies  a  line,  and  each  kind  of 
obser\'ation  a  perpendicular  column.  Eacli  ])age  contains  one  hundred 
lines,  and,  tliercfoiv,  oik^  hiiridi-cd  histories.  The  headings  of  the  fourteen 
pages  which  ajc  devoted  to  tlie  records  of  each  hundred  histories  are  a 
repetition,  in  so  far  as  oi)servations  of  the  fii'st  ten  ))oslpartiim  days  are 
concerned.  Postpartum  observations  which  extend  Ix^yond  tliis  |)eriod  of 
ten  days  are  not  considered  in  this  book.  Such  cas(!s  are  usually  coinidi- 
cated.  and  reeorded  as  such  in  the  card  system  described  b(!low.  'i'he  record 
is  made   by  a  single  mark   in   the  square  formed   by  the  crossing  of  the 


THE    MEDICAL    RECORDS   AXD   THE    PREPARATIOX    OF   STATISTICS. 


29 


appro])riate  lines  and  columns.  The  results  of  each  hundred  histories  are 
totalized  by  adding  the  columns  at  the  foot  of  the  page.  In  the  case  of 
twins,  a  double  mark  is  placed  in  the  squares  of  the  "Record  of  Child,'" 
opposite  the  history's  number. 

The  check  on  the  correctness  of  the  column  totals  on  any  page  is 
obtained  by  adding  the  totals  of  the  subdivision  columns  under  each  sub- 
ject: these  must  always  add  up  one  hundred,  i.e.,  the  number  of  cases 
on  a  page. 

The  figures  obtained  by  adding  the  columns  of  each  hundred  histories 
are  transcribed  to  the  ])roper  columns  of  a  set  of  pages  in  this  large  Sta- 
tistic Book.  In  this  summary  each  line  represents  the  totals  of  one  hundred 
histories,  instead  of  a  single  history,  and  the  results  of  one  thousand 
liistories  are  concentrated  into  ten  lines. 

It  is  possible  to  add  up  at  any  time  the  columns  of  these  summarizing 
pages  and  prepare  a  statistical  report  for  any  number  of  cases.  This  can 
be  done  with  a  minimum  of  work,  and  at  verv  short  notice. 


Headings  of  Laege  Statistic  Book. 
Record  of  Pregnancy. 


sorKCE  or  applica- 

TRIXE. 

BOXY    PELVIS. 

TIOX. 

m 

6      .2 

'A   M   S 

^         >^ 

.   o^   =3 

.     .         ^C    .  ^ 

ai  1^  ;^  .-S  '2 

0  -^       — =-M  P7' 

Jr   o   s   ^S^ 

'•0 

:^  ^        5  ^  S 

•  skill's 

-M 

fo 

X3 

.   ^   ">-*   m   vi. 

?:  5  0  ©0 

d 
•^ 

F  ^  ci  ^    -, 
0  ^  i?.  S  0 

^ 

HP^-^Cw^pHf:^ 

^<^on^ 

TXl  0  RLW  H  hH  H  P 

Lbs. 

Ft.     In. 

Recoi'd  of  Labor 


CIVIL 

BIETHPLACE. 

AGE 

COJSTDITIOX. 

-2 

F— ' 

d 

weden. 

\\dtzerlan( 

Gotland. 

d 

0 

<D 

-^CiTjHOi'^cirJHci'* 

Married. 

Single. 

Widowed. 

©  .5    !Z! 

< 

s  0  ©13  c^  0 

5 

0 

1   1   M   1  1   1   1   1 

0  0  0  0  0  I-O  0  0  0 

»— '  —  — 

X  X :/: 

N-/ 

t— ^ 

" 

C^J  CM 

JO 

IC 

"^ 

-tH   10   kO   0 

30  REPORT   OF   THE    SOCIETY    OF   THE    LYINGIX   HOSPITAL. 

Becord  of  Labor. — (Continued.) 


former  preg 
nancies. 


— 

— 

— 

3 

1. 

— 

~ 

O 

< 

2_ 

X 

'-S 

■r. 

•/■ 

■f. 

•r. 

-/: 

X 

C 

c 

O 

O 

i^ 

> 

>. 

d 

> 

> 

ct 

?^ 

w 

^ 

^ 

P 

h-! 

t-^l^l—lH-lt— !►>>>»—(•— (t—iK.K.(— !»—(>— Ij> 
I— i  r^  y^_     \—{>—{  KNk^i_,t— (K^r'Kl— (I— I 


Mr 


X 


MONTH    OF    CJKSTATION. 


-t^    r^ 


•       iS'Tj-^       _■       r-i"       ^     -*-^    rG    r^ 


Ttecoi'd  of  Lahor. — (Continued.) 


CONDITION 
OF  CHILD. 

URINE. 

PRESENTATION. 

DISPLACEMENT    OF    FOSTAL    PARTS. 

2   S   ^  "H* 

fS  Vertex. 

Ear. 

Brow. 

Face. 

Occijuto  Posterior 

at  Birth. 
Shoulder. 
Breech. 
ISioi  Observed. 

Prolapse. 

Extension. 

Placenta 
Pra3via. 

E  5 

Funis. 

Foot. 

Hand. 

Legs. 

Arms. 

Hands. 

Central. 
Partial. 
Marginal. 

Record  of  Lahor. — (Continued.) 
First  Stage. 


VAOINAL    EXAMINATIONS. 

mkdi(;ation. 

HEMORRHAGE. 

dura- 
tion. 

o 

V>y  Attending  Physician. 

\W  Staff. 

r.y  Statf  and  Pupil. 
r.y  Outside  Attendant. 
Number  not  Observed. 

N'aginal  Douche. 

Whiskey. 

Quinine. 

^[orphine. 

Chloroform. 

Chloral. 

Slight. 

^Moderate. 

Profuse. 

Demanded  Treatment. 

No  Treatment. 

THE   MEDICAL   EECORDS   AND  THE   PREPARATION   OF   STATISTICS. 


31 


Record  of  Lahor. — (Continued.) 
Second  Stage. 


POSITION  AT  TIME 

MEMBRANES. 

VAGINAL    EXAMINATIONS. 

OF  DELIVERY. 

6 

d 

6  S 

•  rt                 -t^  ti 

'^(n 

0                  -   5 

J  ^ 

oi                 .    c;    t> 

^^ 

^      "Es  53 

.^   1 

Ph       ^  bM 

'6 

^"T  ^^' 

(D 

,     Z/i      \      ZD     P 

0 

> 

0 

•^           s  oj  0 

1—1     CD  r—-     CD     O' 

Dorsal. 
Lateral. 

Not  Obs 

Intact. 

Artificia 

Spontan 

Artificia 

Spontan 

Not  Obs 

§  §  g  g  1  ^  >;  ^fjD^  rt 

By  Atte 
By  Staff 
By  Pupi 
By  Staff 
By  Outs 
Number 

Record  of  Lahor. — (Continued.) 

Second  Stage. 


MEDICATION. 

CORD   ABOUT. 

HEMOR- 
RHAGE. 

DURA- 
TION. 

Neck. 

Legs. 

Arms. 

Slight. 

Moderate. 

Profuse. 

Demanded  Treatment. 

No  Treatment. 

Vaginal  Douche. 

Ergot. 

Morphine. 

Chloroform. 

Chloral. 

Once. 
Twice. 

Three  Times. 
Four  Times. 
Five  Times. 

.  <6 
OH 

.  a5 
0  0 

1  ^ 

OH 

to 

Record  of  Lahor. — (Continued.) 
Third   Stage. 


MEDICATION. 


HEMORRHAGE. 


DELIVERY    OF 
PLACENTA. 


IMPLANTATION 
OF    CORD. 


ce   o   © 

a  '^  = 


©  O  05 

Q  ^  <o 

S  O  P2 

■  ■  O 


.B-Z 


>      U      ^      W^OQ 


-J— > 

ID  OS    c|  ^3 

^  S  r3  03  cpj>^ 


iZ2 

O)  o 

c  ^  g  « 

ic  »>    c3  f^ 


:e 


32 


REPORT   OF   THE   SOCIETY   OF   THE   LYING-IN    HOSPITAL. 


Record  of  Lahor. — (Continued.) 


Third  Stage. 


COXDITK»X    OF  I'LACENTA 
AXD    MEMBRANES. 

TEMPERATURE    ONE    HOUR 
AFTER    LABOR. 

PULSE  ONE  HOUR  AFTER 
LABOR. 

-7:  ?  r:  £j  ,.  :£     -2 
(^  Q  'J  <"'5'£  ^  ^ 

^7^  '^fi  ^^  ^^  '^T'  "'T'  ^^  ^-J"  ^I"  ^T* 

1:0  t-^  00*  ci  0  th"  (M'  CO  -*'  ^ 

OiOSOiOSOOOOOO 

TH    T-H    T-t    T-H    T—l    1—1 

1    1    1    1    1    1    1    1    1    1 

10  0  t-^  GO  oi  0  i-H  oi  CO  -+' 

05  Oi  Oi  Oi  O-.  0  0  0  'O  0 

CiOiCiOiCiOiiXOjOiOi 

^lOCOt-COOiOT-HO^CO 

1— (  T— I  1— I  rH 

1    1    1    1    1    1    1    1    1    1 

0  0  0  0  O'  0  0  0  0  0 

'TtiOOl—  QCOiOT-HOTCO 

1—    1— 1    ^H    1— 1 

Record  of  Lahor. — (Concluded.) 


Third  Stage. 


DURA- 

TOTAL  DURA- 

PERINEUM. 

DAY    OF    DISCHARGE. 

TION. 

TION  LABOR. 

1 

. 

<o 

O) 

0 

> 

K" 

«t-H 

T^    <0 

c 

0 

'A 

"■+3 

Pi 
C 

Hours. 

Minutes. 
Not  Obs 

5 

H^  Pl,  o:i  H  P^  P^  X'  oi  W  ^  H 

Daily  Record  of  Mother. 


TEMPERATURE. 

PULSE. 

A.M. 

P.M. 

A.M. 

P.M. 

-f  -f  -+* 

-+■  -r  -f 

-t"  -t  -t 

-t  -+•-+<-+•  -f  -f 

50-  59. 

60-  69. 

70-  79. 

80-  89. 

00-  09. 
100-109. 
110-119. 

ci  oi 

O'l  CO 

1— 1    T-H 

^  J. 

-ri  CO 

T— 1  rH 

«j-  'r^  r: 

J[     1 

■£  ij-  '/> 

i-  9"  r 

CO  ■j;<  »r. 

1—  --  1-4 

'     ;     1 

tr.  t".  tr. 

-ri  CO*  -t< 

ceo 
—  — •  1— t 

96.5-  97 
97.5-  98 
98.5-  99 

0  -^  7 )  CO  ;^  1^ 

1  T  1    1    1    1 

».0  >C  ».0  iC  if5  iC 

cv  0  — -'  oi  CO*  -t< 

Ci  C    C    C    C    'C 

Oi  Oi  Oi  Oi  Oi  Oi  Oi  O".'  Oi 
iO  0  I-  CO  Ci  0  tH  O'l  CO 

T-H  r-H  1— (  rH 

1       1       1       1       1       1       1       1       1 

00000000-0 
lO  'X'  t^  "Xl   Oi   0   rH   O'l   CO 

T—^   r-i   1—f   r—i 

THE   MEDICAL   RECORDS   AND   THE   PREPARATION    OF   STATISTICS. 


33 


Daily  Record  of  Mother. — (Concluded.) 


BREASTS. 

UTERUS. 

LOCHIA. 

Height  above  Symphysis  in  Inches. 

Con- 
dition. 

Normal . 
Caked. 

Lymphangitis. 
Abscess. 
Nipples  Fis- 
sured. 

t 

CD 

>       .    0                                                                                                     ^ 

tH  tH  T— (  r-l  tH  rH 

Firm. 

Flabby. 

Not  Observed. 

Absent. 

Sanguineous. 

Sero-sanguineous. 

Serous. 

Sweet. 

Foul. 

Daily  Record  of  Child. 


w'gt. 

TEMPERATURE. 

CORD. 

EYES. 

A.M. 

P.M. 

^T^  ^ji   'Tji  ^^   ^^  ^^   ^^1   ^^   ^^   ^fi 

^^   ^^   ^T"   ^^   ^^i  ^7"   ^'T'   ^T"   ^^'   '^^ 

Normal. 
Suppurating. 

J2     02 

cicia:>OiOO'OOOo 

tH  rH  r-(  T— I  1—1  T-( 
1       1       1       1       1       1       1       1       1       1 

lOOiOiOiOiOiOiOiOiO 

CCt-GOCiOr-IOTCC-+IO 

CSCSCiOiOOOOOO 

1— 1  rH  rH  rH  r-l  rH 

1       1       1       1       1       1       1       1       1       1 

1 — 1    03 

H 

o  ^ 

O^^Ct^GOCiOr-ICJCO'* 

IC  O  -t-  QO  Oi  O  rH  CM  Oti  ^ 

CI  Ci  Ci  Ci  CI  O'  O  O  O  O 

r-H  rH  rH  rH  rH 

Record  of  Child. 


SEX. 

WEIGHT    AT 

BIRTH. 

c» 

cc 

S 

oted. 
on. 

OJ 

0) 
O 

in 

;3 

O 

c 

i«t:s 

UI^'SS 

\sit^ 

icjo  icjo  ois;  inf©  injto 

irriO  ic:f»  ir$^ 

irsfo  i^':o 

\ri^  \r.fs  if:(» 

«« 

H-H 

-H 

-H 

H'^  H^  HtH  H^  H'-* 

■r^■^   H-H   --M 

H-H    H-i 

H-*   -M   --H 

lo 

t-i 

CM 

OO 

-^    UO    CO   J::-   GO 

Ci     O     tH 

(>T    CO 

'^    lO     CO 

O   .JO     as 

T->. 

T-i     r-{ 

rH     rH 

rH    1— 1    rH 

^<1^ 

1 

rH 

1 

rH 

fM 

1 

CO 

1       1       1       1       1 

-H    lO    O    t^    OO 

1         1          1 

C:     O'     rH 

1         1 
G^     CO 

1         1         1 

-^    lO    CO 

•r^     rH 

•r-\    T^ 

T^      •'-^      T^ 

34 


REPORT   OF  THE   SOCIETV    OF  THE   LYING-IN   HOSPITAL. 


liecm'd  of  Child, — (Continued.) 


VERTEX — COCCYGEAL    LENGTH    AT    BIKTII.  TOTAL    LENGTH    AT    BIRTH. 


■A 

xH' kH' sH  =5*^  «H  =eH' «t*  kH  «^*  kH  kH  mH- kH  «H 

— 1  (M  rt  -+  o  cc^  t-  00  C5  c:  T-i  CM  Of  4i  lo  CO  J^-  CO 

T— IT— It— (tHt— It— It— It— It— 1 
1       1       1       1       1       1       1       1       1       1       1       1       1       I       1       1       1       1 

-tssyi  CO  -<ti  o  w  t-^  00  05  o  T— 1  (M  Of  ^  lo  <:o  t-  GO 

1— 1 

ccH*  kHi  mH  mH"  <=^  =^  <=«H  ^H  ==H*  etH* '^  =^ '=^*  ^ 
T— 1  CM  Of  tJH  IQ  O  t^  OO  05  O'  T-l  Ol  Of  -4l 

T— ^    T-H    T— 1    T— 1    T— ^ 

1    1    1    1    1    1    1    1    1    1    1    1    1    1 

"l<^>(^^  Of  rti  Kf  <:o  i,—  c/:  cr.  C:  t— l  Ol  of  -rH 

T— (     tH     1—1     T—l     T—l 

Record  of  Child. — (Continued.) 


TOTAL  LENGTH  AT  BIRTH. 


JCT^  sc^-t  St-*  sth*  sH":H"^  kH  seH" 
J--:  --Z  I-  X  Ci  C:  -^  Ol  CO 

— I   .^   .r-l  -^   r^   CM   ^1   CM   (M 

I    I    I    I    I    I    I    I 

.  -.   V:   I  -  CO  CI  O  ■^  '?!  CO 
—  ' ^  T-l  T-l  (M  CM  (>5  <M 


TEMPERATURE  AT  BIRTH. 


-t--+i-H-H-H-H-+i-H-+i 

1— 

C5 

CO 
C5 

CI 

T-l 

T^ 

(M  Of  -+I 

o  o  o 

^^    T—l    1—1 

>o 

Vfj 

lO 

vo 

lO 

UO 

lO  lO 

Kf 

IC  CO  1-  CX>  05  O  T— I  OT  CO 

C:'  CI  C^)  CI  Ci  O  O  O'  O' 


CORD    DETACHED    ON. 


Record  of  Child. — (Concluded.) 


£Y£8  AT 

BIBTH. 

DAY    DISCHARGED. 

DICATH    OF   CHILD. 

s«       v* 

^ 

^   -^ 

"Z       J=.             1^^ 

fi^ 

^  r—    *-                     r^  "Z:  _ri  _i=l 

J^  (^  Ph 


9x   C   g   5r-5'S   o^^t:; 

'^.i:  ^..2  o'TZ  i:j  c^ •""•--'  S 


h-5fj-ic/iHfiHPiHCC!c^w;2;EH 


THE   MEDICAL   KECORDS   AND   THE    PREPARATION    OF   STATISTICS.  35 

The  Card  Index. — The  card  system  of  keeping  records  is  too  well 
known  and  too  nniversally  used  to  need  any  description  here.  We  have 
applied  it  to  the  recording  of  the  complications  and  the  exceptional  phe- 
nomena of  our  obstetrical  service.  This  system  is  more  elastic  and  more 
flexible  than  any  record  book.  It  allows  also  of  additions  and  subtractions 
without  mutilation,  and  it  permits  the  handling  and  the  arrangement  of 
the  records  into  various  groups,  as  a  book  cannot.  The  cards  used  are  five 
and  one-half  inches  by  six  and  three-quarter  inches  in  size.  They  are 
printed  on  one  side,  and  after  being  filled  out  are  stored  in  boxes,  each 
kind  of  card  having  its  own  box.  These  boxes  are  kept  in  a  cabinet  built 
for  the  purpose.  Each  important  subject  has  a  special  card,  and  there  is  a 
general  card  for  miscellaneous  subjects.  These  cards  are  reproduced  in 
reduced  size. 


ABORTION. 

Application  No Confinement  No. 


BIRTHPLACE, AGE,....  PARA, ....  MONTE  OF  GESTATION, 

LABOR, 


i   Dispensary. 

DELIVERED  By)  MMwile  ^^^'''''''"' 

PRESENTATION, POSITION, (  Unattended, 

Symptoms, 

Complications, 

Treatment, 


Result,. 


36 


KEPORT   OF  THE   SOCIETY    OF   THE   LYING-IX   HOSPITAL. 


Application  No. 


ACCOUCHEMENT    FORCE. 


Confinement  No, 


Birthplace,- 
Labor, 


Presentation,. 


_Age,.. 


.:Para, Month  of  Gestation,. 

f 


Position,. 


Dispensary. 

.Delivered  by    \  Z""!''^!  Physician. 

Midwife. 
_ Unattended. 


Foetal  Heart,.. 
Indication, 


Compfications, 


Perineum,.... 
Treatment,.. 


Cervix, 


Result,. 


ALBUMINURIA. 

ANTE-PARTUM.     DURING   LABOR.     POST- PARTUM. 
Application  No Confinement  No.. . . 


/i/Ii  rilPLA  CK. \0K PA  It  A MONTH  OF  (I  EST.  1  TlON 

LABOR i  Dispensary. 

DELIVERED  by)  ^[^^^J/^'^''"'""- 

I'RESEXTA  TION, POSITION. (    rimlt.'ii.Ud. 


Symptoms,. 


Previous  Renal  History, 


Urine, 

Complications, 
Treatment, 


Result, 


TJIE    MEDICAL   KECORDS   AND   THE   PREPARATION    OF   STATISTICS.  37 

BREECH    PRESENTATION. 

Application  No, Confinement  No 

Birthplace, Age Para, Month  of  Gestation, 

Labor,  r  Dispensary. 

DELIVERED   BVJ   0,^;i^!|;/'<>--- 

Presentation Position, I  Unattended. 


Pelvis,. 


Soft  Parts, 


Complications, 
Treatment, 


Result, 


BREECH    EXTRACTION. 

Application  No Confinement  No. 


BIRTHPLACE, AGE,....  PARA, ....  210  NTH  OF  GESTA  TION, . 


LABOR, r  Dispensary. 

T^TTT  TT^TPVjpT^   z?  X- )   Out-sidc  Pliyslcian. 
DELUERED  B14   Midwife. 

PRESENTA  TION, POSITION, (  Unattended. 


i  Arms, 
Position  of^ 

(  Legs, . 


Foetal  heart, 

Funis, 

Complications  (after-coming  head), 

Treatment, 


Result, 


38  KEPORT   OF   THE   SOCIETY    OF   THE    LYINU-IN    HOSPITAL. 

BREECH    EXTRACTION,   AFTER   VERSION 

Application  No Confinement  No 


Birthplace Age Para ]\[oxtii  of  Gestation,. 

•  •  •   [  Dispen 
BY -J    ?,'.'S' 

Pkeskxtation'. Position, 


Labor C  Dispensary. 

-r-k  ^   ,,,,  )  Outside  Physician. 
Delivered  bW  ^^.^^^.^^     • 

(   Unattended. 


Presentation  before  version, Position  before  version,. 

\  Arras, 

/  Leijs 


Position  of 


Foetal  heart, 
Funis, 


^  1-       i.-  \      extended  arras. 

Complications  ,  ^fter-coraing  head. 


Treatment  (methods  used,) 


Result, 


CURETTING. 

Application  No Confinement  No. 


BIRTHPLACE, AGE, ....  PARA, ....  MONTH  OF  GESTATION, 

LABOR, 

DELIVERED  B 

PRESE.XTA  TTOX, POSITION. 


■   (  Dispensary. 
Y  ]   Out-side  Physi 


„  sician. 
Midwife. 
Unatleiided. 


Indication, 

Technique,  .  — 
Complications, 

Treatment, 

Result, 


THE   MEDICAL   EECORUS   AND   THE   PREPARATION   OF   STATISTICS.  39 

DEATH   OF   CHILD. 

Application  No Confinement  No 


BIRTHPLACE, AGE, ....  FAB  A, ....  MONTR  OF  GESTATION, 

LABOR, 


(    Dispensary. 

DELIVERED  By)  ^l^^^^^^^^'"'^^'^- 


PRESENTATION, POSITION [  Unattended. 


Age  of  Child, 

Heart, Lungs,. 

Umbilical  Stump, 

Symptoms, 


Autopsy, 


DEATH    OF    MOTHER. 

Application  No Confinement  No. 


BIRTHPLACE, AGE, ....  PARA, ....  3I0NTH  OF  GESTATION, . 

LABOR, 


I    Dispensary. 

DELIVERED  by)  nJawiie.  ■^^^'''"''"" 

PRESENTA  TION, POSITION, I  Unattended. 

Complications  before  delivery, 

Operations  or  manipulations, 


Complications  after  delivery,. 

(  antepartum, 

Day  of  Death,  \ 

( postpartum, 


Autopsy, 

Cause  of  Death, 


4,0  KEPOKT    OF   THE   SOCIEIY    OF   TIJK    JA'IXG-IN   HOSPITAL. 

DEFORMED    PELVIS. 

Application  No Confinement  No. 


Birthplace, Age, Paka Month  of  Gestation,, 


Labok,  [  Hospital. 

T^iiivn^vi^   Tiv  '  Outside  Physician. 
DlLINEKED    B\.  Midwife. 

I'KESr.NTATlON PoSITIOX '  l^'i'i<tended. 


Result, 


DISPLACEMENT    OF    FOETAL    PARTS. 

HANDS,  FEET,   FUNIS. 
Application  No Confinement  No 


/y/A' 77/ /'LA ( '/■: Adl-J PARA, ....  MONTH  OF  GESTA TION, 

LABOR, 

DELIVERED  BY 

/'li/:s/:XTA  T/OX, /'OSTT/ON. 


■   (  Dispensary. 

y  )  Out-side  i'liy: 

"i  Midwife. 

(  Unattended. 


sician. 


Hands, 

Feet, 

Funis, 

Foetal  heart,. . . 
Complications, 


Treatnnent, 
Result, 


THE    MEDICAL   RECOEDS   AND   THE    PREPARATIOX    OF   STATISTICS.  41 

EXTRACTION.)  MEMBRANES. 

Application  No Confinement  No 

BIRTIIPLA  CE, AGE,....  PARA, ....  MONTH  OF  GESTA  TION, 

LABOR, [  r^. 

I    Dispensary. 

DELIVERED  By\  ^^"V'-J''  P'^y^^^'*^"' 

1   Muhvife. 


PRESENTATION, POSITION, '.  Unattended. 


Hemorrhage, 

Condition  of  Placenta, 


Complications, 


Treatment, 


Result, 


FACE    PRESENTATION. 
BROW   PRESENTATION. 

Application  No Confinement  No. 


BIRTHPLACE, AGE,....  PARA, ....  210  NTH  OF  GESTATION, 

LABOR, 


PRESENTA  TION, POSITION, 


Dispensary. 
DELIVERED  By)  ^^^^^^  Physician. 
I   Unattended. 


Pelvis, 

Soft  Parts, 

Complications, 

Treatment,  (manual  rectification.). 

Result, 


42 


REPORT   OF   THE   SOCIETY    OP"   THE    LYING-IN    HOSPITAL. 


FEVER. 


Application  No. 


Confinement  No. 


Birthplace, Age, Para, Month  of  (jestation,. 

Presentation, Position. 


LaISOIi f  Dispensary. 

^^^^^  ^^^^'  ^'^  ^   Midwife. 

f   UnuttondtHl. 


Day 

1 

a  H. 

E 

3 

= 

4 

5 

6 

£ 

3 

1 

7 

£ 

C3 

£ 

5 

g 
c. 

9 

c 

e3 

E 
s. 

10 

1 
a 

r 

12 

5  E 

1 

E 
a 

3 

1 
£ 

4 

£ 

15 

.  .1 . . 

16 

S  £ 

17 

Eia 

18 

e'e 

19 

B   a 

20 

106° 
105° 
104° 
103° 
102° 
I0i° 
100° 
99° 

■•I-- 

y.c. 

'  ' 

98= 
97° 

Pulse 
Res^pi-  1 
ratiuii.  \ 
Hei^bt| 

litem-    \ 

"l 

± 

'.'l 

■■ 

Lochia,. 
Uterus,. 


Breasts,. 

Parametria,. 


Bowels, 

Complications,. 


FCETAL    DEFORMITIES. 


Application  No. 


Confinement  No. 


Birthplace, 

Lai'.oh 


Age, PAii.y. 


Month  of  (Je.station,, 


Pp.ksentation. 


Position, 


r  Dispensary. 

Delivered  by  ->  ^}!f'^'  ^'^'y''''' 

j   iMidwife. 
f  Unattended. 


Foetal  Movements, 

Foetal  Heart, 

Complications  of  Labor,. 


Mother's  History, 


(a)  Con.stitutional, 


(b)  In  pregnancy, 
Father's  History,  (f.'on.slitutional),  ... 

Condition  of  Placenta, 

Condition  of  Child, 

A  utopsy, 


THE    MEDICAL    RECORDS    AND    THE    PREPARATION    OF    STATISTICS.  43 

MEDIUM. 
LOW. 

Application  No, Confinement  No 


BIRTHPLACE, AGE,....  PARA, ....   MONTH  OF  GESTA TION, 

LABOR 


Dispensary. 
DELIVERED  BY  J  ^/Jj-^^^  Physician. 

PRESENTATION, POSITION '   Unattended. 


Foetal  heart 
Indications. . 


Complications, 


Cervix Perineum. 

Treatment, 


Result, 


HEMORRHAGE. 

ANTEPARTUM.     DURING  LABOR.     POSTPARTUM. 
Application  No Confinement  No... 


BIRTHPLACE, AGE,....  PARA, ....  MONTH  OF  GESTATION, 

LABOR 


1    Dispensary. 

DELIVERED  by)  MMwife  ^^^''''''"' 

PRESENTA  TION, POSITION. (  Unattended. 

Antepartum,  (how  long.), . . .  Stage  of  Labor, Postpartum,  (how  long,) 

Cause  of  the  hemorrhage, 

Symptoms, 


Placenta  implantation. 
Condition  of  Placenta, 

Foetal  heart, 

Complications, 

Treatment, 

Result, 


4-i  REPORT   OF   THE   SOCIETY    OF   THE   LYING-IN   HOSPITAL. 

ICTERUS    NEONATORUM. 

Application  No Confinement  No. 


lilltTllI'LAlE, A(ii: PaKA, ^loNTll    OK    (Jl'.STATlOX, 


^■'■'^l^Oli r   Dispensary. 

Delivered  by  J  m'S  ^''•'''''''"' 

Presentation Position, v  Uiuittended. 

Begun  on day  after  birth, 

Subsided  on day  after  birth, 

Complications, 


Treatment, 


Result, 


MAMMARY   ABSCESS  |  ^q^^^P 

Application  No Confinement  No.. 


Birthplace, Age, Para, Month  of  Gestation, 

I^ABOR,    r   DispciiSHiT. 

Delivered  by^  Outside  Physician. 

1    JMidwiic. 


|',;i:<i:nt ATfON- Position '  l'""<<ended, 

Symptoms, 

Complications, 

Treatment,  


Result, 


THE    MEDICAL   RECORDS    AND   THE    PREPARATION    OF   STATISTICS.  45 

OCCIPITO— POSTERIOR    POSITION. 

Application  No Confinement  No 


Birthplace, Age, Para, Month  of  Gestation,... 

^-^^^^^ (  Dispensary. 


Delivered  by^  nSfe.^^^''"''"' 


Presentation Position, I  Unattended. 


Pelvis, 

Soft  Parts, 

Complications, 

Treatment  (manual  rectification), 


Result, 


PERINEORRHAPHY. 

Application  No Confinement  No.. 


BIRTHPLACE, AGE,....  PARA, ....  310  NTH  OF  GESTATION, 

LABOR 


1   Dispensary. 

DELIVERED  By)  ^.^'-side  Physician. 


PRESENTA  TION, POSITION, 


Midwife. 
Unattended. 


Laceration, 

Treatment,  (Technique.) 


Complications, 


Result, 


46 


REPORT   OF   THE   SOCIETY    OF   THE    LYING-IX    HOSPITAL. 


Application  No, 


PLACENTA    PRAEVIA. 

MARGINAL.     PARTIAL.     CENTRAL. 

Confinement  No. 


BIRTHPLACE, AGE,....  I'ARA JIONTII  OF  OESTA  TI(}.\ 

LABOR, 

DELIVERED 

PRESEXTA  TIOX.  (foetal.) POSITION,  (foetal.)  .... 


■  ■  ■   r  Dispensary. 

Ti\')  Out-sido  Physician. 

^^^  i  Midwife. 

I  Unattended. 


Foetal  heart, 
Symptoms,. . . 


Complications, 


Treatment, 


Result, 


Application  No. 


PLURAL   BIRTHS. 


TWINS.     TRIPLETS. 


Confinement  No. 


BIRTHPLACE, AGE,....  PARA,. 

LABOR, 


MONTH  OF  GESTATION. 


PRESENT  A  TION,  I . .  .  TT . .  .  ITT . .  .      POSITION. 
SEN.  T II Ill 


(  Dispensary. 

)  Out-.side  Physioiii 

-  -r        -jy        -,.,         I  Unattended. 


.DELIVERED  BY 


Placenta, 


j  single, . 
(  double, 


one,      1 

Amniotic  cavity,  ^  two,    \ 

three,  ) 

Funis, 


Complications  of  labor,. 


Result, 


THE   MEDICAL   RECORDS   AND   THE   PREPARATION   OF   STATISTICS.  47 

PNEUMONIA. 

Application  No. Confinement  No 


BIRTHPLACE, Aiii:, ....   PARA, ....  2I0NTH  OF  GESTATION, 


LABOR, [  r,- 

'  I    Dispensary. 

DELIVERED  By)   Midwife  ^*'^'''''"''' 

PRESS  NT  A  TION, POSITION I  Unattended. 

Operations, 

Puerperium, 

Pneumonia  began  on day  of  puerperium. 

Pneumonia  terminated  on day  of  puerperium,  (defervescence.) 

Complications, 


Treatment, 


Result, 


SHOULDER    PRESENTATION. 

Application  No Confinement  No. 


Birthplace, Age, Para, Month  of  Gestation,  . 


L-^^O^'  (  Dispensary, 

Delivered  by  J  MMtife.^^'"''''''''' 

Presentation, Position, I  Unattended. 


Pelvis,. 


iArms, 
Legs, . 


Funis, 

Complications, 

Treatment, 

Result, 


48  REPORT   OF   THE   SOCIETY   OF   THE   LYIXG-IX   HOSPITAL. 

STILL   BIRTH. 

Application  No Confinement  No. 


BIllTlIPLACE, AGE,....  PARA, ....  MONTH  OF  GESTATION, 

LABOR 


(   Dispensary. 

DELIVERED  By\  mJ^S.  ^'''^''^''''"• 


PRESEXTA  TIOX. POSITION, \  Unattended. 

Foetal  Movements, 

Foetal  Heart,  

Complications  of  Labor, 


i  (a)  Con.stitutional, 
Mother's  History, -I 

(  (b)  In  pregnancy, 


Father's  History,  (Constitutional.) 

Condition  of  Placenta, 

Condition  of  Child,  (macerated,). 
Autopsy, 


SUPPURATION   OF  UMBILICAL  STUMP. 

CONJUNCTIVITIS.  I  bo"eyes. 

Application  No. Confinement  No 


lilR TIIPLA CE AGE,....  PARA,....   MONTH  OF  GESTA TION, . 


LA  BOR (  Dispensary. 

DELIVERED  by)  l^^^^^-- 

I'UFSENTA  TION, position, (  Unattended 

Begun  on day  after  birth, 

Subsided  on day  after  birth, 

Complications, 


Treatment, 


Result, 


THE   MEDICAL  RECORDS   AND   THE   PREPARATION    OF   STATISTICS.  -19 

VERSION.  I -rua- 


Application  No Confinement  No. 


BIRTHPLACE, AGE,....  PARA, ....  3I0NTH  OF  GESTA TION, 


LABOR, (  Dispensary. 

Out-side  PI: 

Midwife. 

Unattended 


DELIVERED  by}   Sia'wSe. ^^^'''"''''' 


PRESEXTA  TIOX, POSITION, 


Foetal  heart, 
Indications,.  - 


Connplications, 


Perineum, Cervix, 

Hand  used, 


Treatment, 


Foot  seized, , 


Result, 


Application  No^ Confinement  No. 


Birthplace, Age, Para, Month  of  Gestation,, 


Labor.  . . .  .• c  Hospital. 

D-^™™  byJ  g°«;fh: 

Presentation Position, v  Unattended 


Result, 


50 


REPORT   OF   THE   SOCIETY   OF   THE    I.VIXC-IX    HOSPITAL. 


The  checks  on  these  cards  are  the  following: 

1.  A  cross  index  of  all  the  other  cards  belonging  to  that  particular  his- 
tory is  -written  under  "  Labor "  on  the  heading  of  each  card.  This 
l)erniits  one  to  compare  the  cards  of  any  history  with  one  another. 

2.  The  number  of  cards  demanded  by  each  history  is  recorded  under 
the  column,  '' Xumber  of  Cards,"  in  the  large  Statistic  Book.  The  total 
of  this  column  gives  the  number  of  cards  in  every  hundred  histories. 

o.  The  number  of  cards  is  recorded  also  in  a  special  Card  Tally  Sheet, 
on  which  each  line  represents  one  hundred  histories,  and  the  columns 
represent  the  kinds  of  cards  (see  accompan3dng  figure  for  a  sample  of  such 
a  sheet).  The  totals  of  the  lines  give  the  number  of  cards  in  each  hundred 
histories,  and  the  totals  of  the  columns  give  the  numbers  of  cards  of  each 
kind. 

Sample  Card  Tali-y  Shee;t. 


2 

c  o 

3    O 

.2 

o 

i 

.5 
1 

d 

0 
a 

0 

Qi 

0 

Q 
«f-i 

0 

Pi 

S 
0 

6 

03 

g 

0 

5001-5100 

4 

1 

1 

6 

8 

1 

2 

0 

S 

etc. 

52 

51 01 -.5200 

2 

0 

2 

3 

5 

3 

1 

1       f; 

etc. 

()2 

etc. 

etc. 

etc. 

etc. 

etc. 

etc. 

etc. 

etc. 

etc. 

etc. 

etc. 

etc. 

"We  thus  have  the  total  number  f)f  cai-ds  recorded  in  two  places:  in  tlie 
large  Statistic  Book,  where  it  is  itemized  on  the  basis  of  the  individual 
history;  and  on  tlu;  tally  sluict,  where  it  is  itemized  on  the  basis  of  the 
individual  cards.  If  any  card  is  not  made  out,  the  two  totals  will  not 
tally.     If  any  card  once  made  out  is  lost,  the  number  of  the  remaining 


THE    MEDICAL    RECORDS   AND    THE    PREPARATION    OF   STATISTICS.  51 

cards  will  not  tally  with  these  totals.  The  missing  card  can  be  located  in 
the  proper  hundred  of  histories,  and  it  must  then  l^e  supplied  by  refer- 
ence to  the  histories  themselves. 

Such  is  the  method  of  preparing  statistics  which  is  used  Ijy  the  Medical 
Board  of  this  Society.  It  means  an  outlay  of  a  certain  sum  of  money  for 
tlie  payment  of  a  permanent  clerk  and  for  the  necessary  stationery.  The 
expense,  however,  need  deter  l)ut  few,  for  one  thousand  dollars  will  more 
than  cover  the  annual  outlay.  By  such  a  system  the  more  routine  part  of 
the  work  can  be  kept  in  a  condition  of  constant  readiness  for  publication. 
Of  course  there  will  remain  for  the  members  of  the  Medical  Board  a  large 
expenditure  of  time  and  special  work  before  each  report  is  edited  and 
published. 


PRACTICAL    IXSTRUCTIOX    GIVEN   BY   THIS   HOSPITAL  TO 
GRADUATE   AND   UNDERGRADUATE   PUPILS. 

Practical  instruction  is  divided  to-d;iy  into  five  classes,  as  follows: 

A.  A  Course  of  Preliminary  Instruction  is  given  to  Graduate  and  Under- 

graduate Pupils  alike,  which  includes  : 

a.  The  Care  and  Preparation  of  the  Sui'gical  Dressings  Used  in  the  Service 

of  the  Hospital. 

b.  The  Care  and  Uses  of  the  Contents  of  the  Labor  and  Postpartum  Bags. 

c.  The  Keeping  and  Recording  of  the  Histories  of  Pregnancy,  Labor,  and 

Child. 

d.  The  Principles  of  Asepsis  and  Antisepsis,  especially  as  Applied  to  the 

Examining  Hand. 

e.  And,  finally,  the  Principles  in  the  Treatment  of  Normal  Labor,  and 

the  Care  of  the  Puerperal  Woman  and  her  Child. 

B.  Examination  of  Pregnant  Women. 

a.  Antepartum  Instruction. 

C.  The  Care  of  Labor  Cases. 

a.  Intrapartum  IiLstruction. 

D.  Treatment  of  Mother  and  Child  after  Confinement. 

a.  Postpartum  Instruction. 

1.  Outdoor  or  Dispen.sary  Service. 

2.  Indoor  or  Ward  Service. 

E.  Obstetrical  Clinics— Normal  Labor  and  Obstetric  Surgery. 


A.    Preliminary  Instruction. 

As  far  as  possil>l(',  the  M<!dic;d  Hoard  aim  at  a  graded  course  of  in- 
struction for  the  und(;rgra<luates  entering  u})on  their  two  weeks'  term  of 
service.  To  this  end  the  junior  pupil,  during  tlie  first  few  days  of  his  service, 
is  required  to  ol).serve  the  management  of  the  confinements  in  tlie  ol)stetrical 
clinics  of  the  Institution  or  in  tlu^  outdoor  service,  and  to  visit  puerperal 
Avonien  and  their  chiidi'cn  i!i  the  tenement  houses.     lie  is  instructed  in  the 


Fig.  1. — Labor  Bag. 
{From  a  photograph.) 


PRACTICAL    INSTRUCTION    GIVEN   BY    THIS    HOSPITAL. 


53 


care  of  mother  and  cliiul,  both  in  the  wards  and  outdoor  service,  as  well  as 
in  the  contents  of  the  labor  and  postpartum  bags  and  their  uses. 

It  may  be  stated  here  that  students  are  termed  Juniors  in  the  lirst,  and 
Senioi's  in  the  latter,  half  of  their  term  of  service.  As  soon  as  the  student 
has  sio-ned  his  name  to  the  rules  of  the  Institution  and  been  assio-ned  to  his 
quarters,  he  is  given  the  above  preliminary  instruction  by  one  of  the  resi- 
dent staff  especially  appointed  for  the  purpose. 

The  bag  used  by  the  Hospital  to  carry  the  articles  needed  at  a  confine- 
ment case  in  the  tenements  is  opened  and  emptied  before  the  students,  and 
its  contents  severally  described,  together  with  the  importance  of  cleanli- 
ness in  their  use.     (See  Fig.  1.) 


Society  of  the  Lying -In  Hospital 

OF    THE    CITY    OF    NEW    YORK. 


CONTENTS  OF  LABOR   BAG. 


Right  Side  of  Bag. 

ALCOHOL. 

Bottom  Pocket. 

THREE   BASINS. 

ERGOT. 

ACETIC  ACID. 

SILVER  NITRATE  SOLUTION. 

RUBBER  CATHETER. 

TAPE  FOR  CORD. 

Centre  of  Bag. 

STERILIZED  VULVA  PADS. 

STERILIZED  COTTON   WiPES. 

PELVIMETER. 

OBSTETRICAL   PAD. 

DOUCHE  BAG. 

Left  Side  of  Bag. 

EYE    WIPES  in  Boracic  Acid. 

BOTTLE  CONTAINING 
TWO  DOUCHE  TUBES, 

ONE  GLASS  CATHETER. 

DRY  WIPES(Umbilical  Dressings). 

SOAP. 

VASELINE. 

BICHLORIDE    TABLETS. 

Left  Cover  of  Bag. 

SCISSORS. 
EYE  DROPPER. 

POWDERED  STARCH. 
C.  C.   PILLS. 

Bight  Cover  of  Bag. 

SIX  REPORT  BLANKS. 

Top  Pocket. 

SCALES. 

NAIL  BRUSH 

TAPE   MEASURE. 

LABOR   RECORD. 

CHILD'S  RECORD. 
BIRTH  CERTIFICATE. 
APPLICATION   CARD. 

STUDENT'S  PAD. 

1.— Before  leaving  case,  pupils  must  see  that  all  of  above 
articles  are  returned  to  bag. 

2.— Jars  containing  vulva  pads,  cotton  wipes  and  catheters,  are 
not  to  be  opened  until  required  for  use. 

3.— All  bottles,  instruments,  rubber  apparatus,  etc.,  must  be 
■wiped  dry  and  free  from  blood  stains  before  being  returned 
to  labor  bag-  Students  will  be  held  responsible  for  any 
damage  to  labor  and  postpartum  bags  resulting  through 
uncleanliness  or  carelessness. 


54 


REPORT   OF   THE   SOCIETY"    OF   THE   LYING-IX    HOSPITAL. 


The  same  iiistriictiou  is  then  liiven  in  the  cave  and  use  of  the  bag  used 
bv  the  IIos]Htal  in  visitini];-  niothet's  and  their  children  after  confinement. 
(See  Fig.  i'.) 

Society  of  the  Lying-in  Hospital 

OF  THE    CITY   OF    NEW    YORK. 


CONTENTS  OF  POSTPARTUM  BAGS. 


Itiuht  Side  of  Bag. 

EYE  WIPES  IN  BORACIC  ACID. 
DRY  WIPES  (Umbilical  Dressing). 


Left  Side  of  Bag. 

SOAP. 
BICHLORIDE  TABLETS. 


Upper  Pochet. 

NAIL  BRUSH. 
TAPE  MEASURE. 


Lower  Pocket. 

STARCH. 
C.  C.  PILLS. 


Centre  of  Bag. 

STERILIZED  VULVA   PADS. 

STERILIZED  COTTON  WIPES. 

BASIN. 


1. — Before  leaving  case,  pupils  must  see  that 
above  articles  are  returned  to  bag. 

2. — Jars  containing  vulva  pads,  cotton  wipes  and 
catheters,  are  not  to  be  opened  until  re- 
quired for  use. 

3. — All  bottles,  instruments,  rubber  apparatus,  utc, 
must  be  wiped  dry  and  free  from  blood 
stains  before  being  returned  to  labor  bag. 
Students  will  be  held  responsible  for  any 
damage  to  labor  and  postpartum  bags  re- 
sulting through  uncleanliness  or  carelessness. 


At  this  lime,  as  a  ])i<'lnniii;uy  lo  the  later  instruction,  the  general  rules 
of  asepsis  and  antisepsis  are  gone  over  with  especial  reference  to  the  exam- 
ining ])and,  an«l  to  those  are  added  tlie  general  principles  in  the  treatment 
of  normal  labor  and  the  ])uej-|)ei-al  woman  and  hei- child. 

The  in.structor  then  introduces  the  ])ii|»il  to  the  history-room  of  the 
Hospital,  jtroduces  a  series   of   history   l>lanks,   and  e,\])lains  In^w,   when, 


Fig.  2. — Postpakttjm  Bag. 
(From  a  photograph.) 


PRACTICAL    INSTRUCTION    GIVEN    BY   THIS   HOSPITAL. 


55 


and  where  the  observations  called  for  upon  the  latter  are  to  be  recorded. 
(See  Histor}''  Blanks.) 

A  blank-book  called  the  "  Student's  Record  "  is  then  given  to  the  pupil 
(see  below),  in  which  he  is  instructed  how  to  enter  the  (1)  number  of 
cases  confined,  (2)  the  number  of  cases  at  which  he  was  present,  (3)  tlie 
number  of  antepartum  examinations  made,  and  (4)  the  number  of  post- 
partum visits  made. 

This  Record  is  verified  from  time  to  time  by  the  instructor,  and  later 
corrected  by  comparison  with  a  general  record-book  of  students'  work 
kept  by  the  Hospital. 


STUDENT'S    RECORD. 


\idime, 

SerOice  be^an_ 
"    •    ended. 


J86)_ 
J8G). 


DATE. 


CONFINED 

CASES 
No. 


PRESENT 

AT  CASES 

No. 


VISITED 

CASES 
No. 


EXAMINED 

CASES  -  A.  P. 

No. 


56  REPORT   OF  THE   SOCIETY    OF   THE   LYIXG-IN    HOSPITAL. 


Pi.   TiiK  ExA:\nNATio.\  (1f  Pregnancy — ANrKfAuiiM  Instkictiox. 

At  the  ])ivsent  time  most  of  the  antepartmu  instruction  of  this  Insti- 
tution is  carried  on  in  the  main  Hospital  building,  and  this  work  continues 
tiirough  the  student's  two  weeks"'  term  of  service.  The  instruction  in  the 
examination  of  pregnancy  has  been  systematized  during  the  past  year  by 
the  Medical  Board,  so  that  each  student  examines  and  records  the  history 
of  pregnancy  on  an  average  of  O.O-i  cases  under  comjietent  and  critical 
supervision. 

The  examiniuff-rooms,  three  in  number,  are,  dui-inii,-  live  afternoons  of 
the  week,  under  the  charge  of  the  Assistant  Attending  Physicians.  \\\\o 
serve  in  rotation. 

Patients  apply^ing  for  admission  to  the  outdoor  oi-  ward  service  of  the 
TIos])ital  are  subjected  to  a  thorough  examination,  and  unless  the  case 
be  an  emergency  one,  the  services,  of  the  Hospital  are  refused  unless  the 
patient  submit  to  such  examination  of  pregnancy. 

Under  the  supervision  and  criticism  of  the  assistant  attending  })hysi- 
cian  on  dut}',  students  are  required  to  make  a  thorough  examination  and 
diagnosis  of  pregnancy,  including  pelvimetry,  and  properly  to  fill  out  the 
History  of  Pregnancy. 

The  Medical  Board  has  seen  fit  to  make  this  record,  as  well  as  the  sub- 
se(|uent  history  blanks  of  Labor  and  of  the  Child,  fuller  and  more  detailed 
in  their  requirements  than  perhaps  the  ])urely  medical  records  of  the 
Hosi)ital  would  demand.  This  is  done  in  order  to  bring  out  the  student's 
faculties  of  observation,  and  a  Avider  consideration  of  the  subject  than  is 
generally  considered  necessary. 

^Moreover,  this  is  the  time  we  have  selected  to  inculcate  in  the  student 
the  ])rinci})les  of  obstetric  cleanliness,  mechanical  and  chemical.  Soa]), 
brushes,  bowls  of  mercuric  chloride,  and  an  aliundant  and  convenient  water 
sujiply  are  to  be  found  in  the  examining-rooms  of  the  Institution.  And 
under  critical  supervision,  each  student  is  required  to  carry  out  the  same 
rigid  cleaning  and  disinfecting  of  the  hand  and  forearm  in  his  examination 
of  ])regnancy  as  in  the  confinement  cases. 

It  is  the  aim  of  the  .Medical  Board  to  have  these  examinations  of  the 
dispensary  women  resemble  as  nearly  as  possible  the  "touch  courses"  of 
the  foreign  maternities.  Two  students,  after  a  thorougli  cleaning  of  the 
hands,  examine  a  ca.se  of  pregnancy  botli  externally  and  internally.  The 
instructor  in  charge  then  examines  the  case,  and  questions  the  students 
regarding  the  general  condition  of  the  ])atient,  the  pei'iod  of  gestation, 
posture  and  presentation  of  the  fcrtus,  condition  of  tlie  nianimary  glands, 
anterior  abdominal  walls,  external  genitals,  and  pelvic  contents,  together 
with  the  size  of  the  bony  pelvis,  and  departures  from  tJK',  normal  in  1h(^ 
hard  and  soft  parts. 

i'ai-ticuhir  attention  is  at  this  time  <:iven.  lii'st,  tr>  llie  siz(^  of  the  jx'his; 
and,  second,  to  the  size  of  the  fu'tal  head.  K.xaminations  thus  carried  out 
under  the  eye  of  the  insti-nctoi-,  with  attention  to  iniiiiitc  details,  as  well  as 


PRACTICAL    INSTRUCTION    GIVEN    BY   THIS    HOSPITAL.  57 

o-eneral  observations  in  the  examination  and  care  of  even  a  few  cases  of 
pregnancy,  will  prove  of  far  greater  advantage  to  the  student  than  a  much 
greater  number  of  cases  of  pregnancy  examined  by  him  without  direct 
instruction  and  supervision. 

C.   The  Care  of  Labor  Cases— Intrapartum  Instruction. 

The  pupil's  training  in  the  care  of  w^omen  during  labor  is  obtained 
during  his  junior  week  by  acting  as  assistant  to  senior  pupils  when  the 
latter  are  sent  to  cases  of  labor  in  the  tenements,  and  in  his  senior 
week  by  himself  taking  charge  and  caring  for  the  woman  in  labor,  in  turn 
assisted  by  another  junior  pupil,  but  always  under  the  su])ervision  and 
criticism  of  members  of  the  resident  Hospital  staff. 

Juniors,  as  well  as  seniors,  during  their  term  of  service,  are  required  to 
attend  the  obstetric  clinics  of  the  Hospital. 

The  junior  pupil,  early  in  his  term  of  service,  accompanies  one  of  the 
senior  pupils  when  the  latter  responds  to  a  call  from  a  labor  case  in  the 
tenement  district.  At  these  calls  the  junior  acts  in  the  capacity  of  an 
assistant  to  the  senior  pupil,  and  the  latter,  in  turn,  as  assistant  to  the  one  of 
the  resident  staff  of  the  Hospital  who  visits  the  case  immediately  after  the 
two  pupils.  It  is  under  the  supervision  and  criticism  of  this  resident  staff 
officer  that  the  treatment  of  the  case  is  carried  out. 

Although  the  Institution  permits  of  confinements  being  carried  out  by 
the  senior  pupil,  in  normal  uncomplicated  cases,  under  supervision  of  the 
staff  officer,  still,  as  the  rules  which  he  has  already  read,  and  to  which  he 
has  subscribed,  state,  the  student  is  debarred  from  prescribing  for  any  case, 
from  performing  any  obstetric  operation,  interfering  in  malpresentations 
or  positions,  or  even  giving  an  intrauterine  douche.  All  such  questions  as 
these  are  referred  to  the  supervising  staff  officer,  or,  in  his  absence, 
directly  to  the  Kesident  Physician  at  the  Hospital,  by  means  of  the  printed 
blank  with  which  all  labor  bags  are  provided.  In  order  that  the  Resident 
Physician  may  keep  in  touch  with  the  progress  of  all  cases  in  the  outdoor 
service,  both  normal  and  abnormal,  the  accompanying  printed  blank  has 
been  made  more  comprehensive  than  would  seem  necessary,  and  the  senior 
pupil  is  required  to  send  in  every  two  hours  reports  of  the  progress  of  his 
case  to  the  Resident  Physician.     (See  Blank  on  page  59.) 

The  junior  pupil  thus  has  the  opportunity  of  witnessing  the  practical 
application  of  the  rules  governing  his  present  and  future  conduct,  in  the 
first  few  days  or  hours  of  his  service.  He  now  sees  the  paraphernalia  of 
the  labor  bag  put  into  actual  use.  He  arranges  the  bed  in  as  cleanly  a 
manner  as  possible ;  assists  in  securing  the  necessary  hot  water  and  in  the 
preparation  of  the  mercuric  chloride  solution  for  the  hands  and  external 
genitals ;  cleanses  his  hands  and  forearm  in  the  manner  already  taught  at 
the  Hospital;  washes  the  patient's  external  genitals  first  with  soap  and 
water,  and  then  with  a  sublimate  solution,  using  the  sterilized  cotton  con- 
tained in  the  labor  bag ;  after  further  cleansing  of  his  hands,  follows  the 
senior  pupil  in  examining  the  patient  internally,  and  is  shown  how  to  enter 


58  REPORT   OF   THE   SOCIETY    OF   THE    LYING-IN    HOSPITAL. 

his  diagnosis  upon  thi'  Labor  ("luirt,  as  well  as  tlio  nuiiil)ei'  and  time  of  bis 
internal  examinations,  to  wlucli  he  is  required  to  sign  liis  name. 

Here  it  will  be  well  to  describe  the  system  by  means  of  which  the  senior 
and  junior  pupils  are  assigned  to  cases  of  continement,  and  the  checks  and 
sujiervision  brought  to  bear  upon  them  by  the  resident  staff,  so  as  to  ])re- 
vent  accident  and  bring  the  case  to  a  successful  termination. 

1.  The  two  pupils  lirst  on  call  are  summoned  by  the  office  clerk  upon 
the  receipt  of  the  Hospital  of  a  demand  from  one  of  its  patients  for  med- 
ical attendance. 

2.  Proceeding  to  the  oiRce,  they  find  awaiting  them  a  labor  bag  (see 
Fig.  1),  and  the  Antepartum  History  Blank  of  the  case  in  question,  upon 
which  the  patient's  address  is  recorded. 

3.  V])on  a  blackboard  provided  for  the  purpose  the  i)upils'  names  and 
destination  are  then  written,  and  u})()n  another  l)oard  the  number  of  the 
lal)or  bag,  so  that  record  may  be  kept  of  the  whereal)0uts  of  the  pupil  and 
the  nosi)ital  property. 

4.  Arriving  at  the  patient's  home,  the  bag  is  })artly  unpacked  and 
arrangements  made  for  the  examination  of  ])regnancy.  The  finger-nails 
are  cleaned,  and  the  hands  and  forearms  of  the  pupils  are  washed  and 
disinfected  after  the  prescribed  rules  of  the  service.  The  junior  pupil  then 
adjusts  the  Kelly  pad,  Avashes  the  lower  abdomen,  up])er  thighs,  and 
genitals  of  the  patient,  first  with  soap  and  water,  and  then  with  sublimate 
soluti(jn.  Pupils  are  instructed  at  this  time  to  expose  tlie  woman  as 
little  as  possible.  Patients,  although  tenement-house  and  charity  ones, 
are  treated  with  the  same  attention  and  consideration  as  those  of  private 
practice.  Tlie  external  examination  of  pregnancy  is  then  made  b}'  both 
pupils,  and  by  abdominal  ])alpation  the  attempt  is  made  to  determine  the 
presentation  and  |)osition.  The  situation  and  rate  of  the  foetal  heart  are 
then  noted  and  recorxled. 

.").  The  hands  and  forearms  of  the  pupil  are  then  scrubbed  for  three 
minutes  with  soft  soap  and  nail-brush  in  hot  water,  and  subsecpiently  in  a 
solution  of  corrosive  sublimate,  and  the  vaginal  examination  of  ])regnancy 
is  made.  As  a  routine,  the  pupil  is  required  to  make  the  following  obser- 
vations is  this  examination: 

(1)  Is  pregnancy  present? 

(2)  Is  the  woman  in  labor  ? 

(8)  AVhat  is  the  stage  of  labor  ? 

(4)  The  condition  of  the  os,  size,  dilatal>ility. 

(5)  The  position  and  ])resentation. 
(0)  The  internal  conjugate  diameter. 

(7)  Any  apparent  dis})ro])ortion  between  the  ])resenting  ])art  and  tlic 
size  of  the  ])elvis. 

The  pupil  then  ascertains  the  condition  of  the  bowels,  bladder,  stomach 
(food),  and,  if  n(!C«;ssary,  shall  sec;  to  the  emj)tving  of  tlie  two  former. 

The  senior  })U])il  is  expected  to  instruct  his  junior  in  the  minor  details 
of  the  management  of  the  first  and  tliird  stages  of  labor,  as,  for  instance, 
the  care  of  thr-  finKhis  uteri  during  these  two  stages. 


PRACTICAL    INSTRUCTION    GIVEN    BY   THIS    HOSPITAL.  59 

6.  The  first  report  to  the  Resident  Physician  is  at  this  time  made  out 
and  dispatched  by  the  husband  of  the  patient,  or  one  of  the  household,  to 
the  main  Hospital  building,  or,  if  more  convenient,  to  tlie  sub-station  in 
Broome  Street;  from  there  it  is  telephoned  to  the  Hospital.  A  copy  of 
this  blank  is  herewith  ap])ended: 


SOCIETY   OF    THE   LYING-IN    HOSPITAL    OF    THE   CITY   OF 

NEW   YOPtK, 
251  East  IYth  St.,  New  York  City. 


When  sending  to  the  Hospital  for  assistance,  students  must  in  all  cases 

use  and  fill  out  this  blank. 


New  York, o'clock, M. 

Patient's  Name, 

Address, 

House, Floor, Room, 

Number  of  Pregnancy, 

Month  of  Gestation, 

Duration  of  1st  Stage, 

"  2d     "         

3d     "         

Pulse, Temp., 

Foetal  Heart  (frequency), position, 

Dorsal  plane, 

Head,  .' 

Small  parts, 

Movements, 

Presentation, Position, 

Os  uteri  (size), condition, 

Membranes,  

Above  brim, 

Engaged, 

At  "outlet, 

•-  On  Perineum, 

Character  and  frequency  of  labor  pains, 


Foetus 

by  abdominal 

palpation, 


Presenting  part,  - 


General  conditions  and  remarks : 


Attendant. 


60  REPORT   OF   THE   SOCIETY    OF   THE    LYING-IN    HOSPITAL. 

In  ordinai-v  uncomplicated  cases  these  reports  of  the  progress  of  the  case 
are  sent  in  at  two-hour  intervals.  In  ])rinnparfe,  a  report  is  returnable 
Avhen  the  os  is  fully  dilated,  and  in  all  eases  at  the  completion  of  the  second 
and  third  stages  of  labor. 

In  com])licated  cases,  or  in  tho  ])resence  of  sudden  emergencj'',  reports 
are  disjiatched  as  often  as  the  necessities  of  the  case  may  demand. 

7.  Following-  soon  uptm  the  departure  of  the  students  from  the  llos- 
j)ital,  the  member  of  the  resident  staff  first  on  regular  turn  visits  the  case, 
gives  what  instruction  is  necessary  to  the  ])upil,  and,  in  many  cases  of 
primi})ara\  takes  charge  of  the  l)irtli  of  the  head  and  shoidders. 

At  the  completion  of  the  second  stage  of  labor,  the  fundus  of  the 
uterus  is  given  over  to  the  care  of  the  junior  pn])il,  while  the  senior  gives 
his  entii'c  attention  to  the  care  of  the  new-born  child. 

The  throat  and  eyes  of  the  child  are  wiped  out  witli  tlie  Ijoracic  wipes 
provided  in  the  labor  l)ag.  (See  Labor  Bag.)  It  is  the  teaching  of  the  II os- 
]>ital  that  the  eye  should  be  wiped  away  from  the  nose,  and  that  a.  separate 
wij)e  should  be  used  for  each  eye. 

Ilespiration  in  the  child  is  now  established,  and  unless  there  is  some 
positive  contra-indication,  it  is  the  custom  of  the  Hospital  not  to  tie  the 
umbilical  cord  until  the  pulsations  cease.  The  usual  two  ligatures  are  used 
in  our  services,  and  after  division  of  the  cord,  the  foetal  stump  is  carefull}'- 
washed  with  mercuric  chloride  solution,  and  a  drv  occlusion  dressiner 
a])j)lied. 

8.  The  third  stage  having  been  successfull}?^  completed,  the  senior  pupil, 
assisted  In'  the  junior,  aibninisters  a  vaginal  sublimate  douche. 

0.  It  then  becomes  the  junior  pupil's  duty  to  hold  the  fundus  uteri  for 
one  hour,  carefully  watching  for  dangerous  relaxation. 

10.  In  the  meantime,  the  senior  pupil  Aveighs  and  measures  the  child, 
stri]ts  and  dres.ses  the  cord.     (See  History  of  Child.) 

11.  The  mother  is  then  cleansed  of  blood,  wet  bedding  removed,  the 
abdominal  bandage  and  vulva  pad  adjusted,  and  her  pulse  and  temperature 
finally  taken  and  recorded.     (See  Labor  Chart.) 

The  labor  bag  is  now  repacked,  each  article  being  checked  off  fi-om  the 
printed  list  found  on  the  cover,  and  the  ])U})ils  j-eturn  with  it  to  the  Hos- 
pital, and  there  the  senior  pupil  makes  his  linal  re])o]'t  to  the  Resident  Staff 
Ollicei-  <jf  the  condition  of  the  ])atient  when  last  seen. 

The  pupils'  names  are  now  erased  from  the  Mackboard  in  the  office,  and 
they  boconie  last  on  turn,  awaiting  an  ap|)ointment  to  anotlier  case,  and 
the  recei[)t  of  the  labor  bag  is  recorded,  with  its  nund)er. 

Jj.    Ti;i;aimknt  ok  Afo'iiiKif    and   Ciiii.I)    Airi:i;    Cuminkmknt — Pos'ii-AirniM 

Insti.-i  criox. 

(^/j    (hifiloar  or   Disjx tisarij  Scrrtce. 

In  the  treatment  of  puei'|)eral  women  and  th«.'ir  childi-en,  as  in  the  care 
of  confinement  cases,  the  Hospital  utilizes  the  material  (^f  both  outdoor 
and  ward  services  for  purposes  of  itist ruction. 


PKACTICAL    INSTRUCTION    GIVP:N    BY   THIS   HOSPITAL.  61 

In  this  Hospital  tlie  postpartum  instruction  given  to  graduate  and 
undergraduate  pupils  occurs  early  in  their  hospital  course.  In  both 
instances,  the  first  postpartum  calls  are  made  in  the  company  of  a  member 
of  the  resident  staff  who  is  expected  to  give  systematic  instruction  in  the 
work. 

Arriving  at  the  house  of  the  patient,  the  pupil,  under  the  critical 
supervision  of  the  instructor,  cleanses  his  hands  and  forearms  according 
to  the  regulations  of  the  Hospital. 

Having  brought  with  him  the  ])ostpartum  bag  already  illustrated  and 
descril)ed,  the  pupil  is  instructed  in  the  making  of  the  necessary  solution 
of  sublimate. 

While  Avaiting  for  the  tablet  of  mercuric  chloride  to  dissolve,  the  aspect 
of  the  patient  is  noted,  and  record  is  made  of  the  temperature,  and  the 
condition  of  the  bowels,  breasts,  and  bladder. 

The  hands  of  the  pupil  are  again  cleansed.  With  the  exercise  of  the 
greatest  care  that  his  hands  come  in  contact  with  absolutely  nothing 
between  the  mercuric  chloride  solution  and  the  vulva  of  the  woman,  the 
vulva  pad  is  removed  from  the  patient,  the  character  of  the  lochial  dis- 
charge upon  it  carefully  noted,  and  the  hands  are  a  third  time  dipped  in 
the  mercuric  chloride  solution. 

The  genitals  are  then  carefully  washed  with  fresh  mercuric  chloride 
solution  with  the  sterilized  cotton  provided  in  the  postpartum  bag,  and  a 
fresh  vulva  pad  applied.     (See  Contents  of  Postpartum  Bag.) 

After  this  the  height  of  the  uterus  above  the  symphysis,  the  sensitive- 
ness and  contractibility  of  the  uterus,  and  the  condition  of  the  iliac  fossae 
are  noted,  and  the  abdominal  binder  reapplied. 

The  pulse  of  the  patient  is  taken  both  at  the  beginning  and  at  the  end 
of  the  postpartum  call. 

It  is  customary  at  present  for  the  pupils  of  the  Hospital  to  carry  note- 
books in  which  are  entered,  by  means  of  a  rubber  stamp,  a  copy  of  the  diur- 
nal observations,  to  be  made  at  the  postpartum  visit,  for  mother  and  child. 
The  pupils  are  required  to  copy  these  observations  in  ink,  in  their  proper 
places  on  the  history  charts  of  Mother  and  Child  upon  the  day  of  the 
observation. 

The  mother  being  attended  to,  the  pupil  directs  his  attention  to  the 
child.  His  hands  are  again  scrubbed  in  the  solution  of  mercuric  chloride, 
and  the  umbilical  cord  of  the  child  is  dressed  according  to  the  prevailing 
custom  of  the  Hospital. 

The  condition  of  the  child's  eyes,  skin,  bowels,  and  bladder  are  noted 
and  entered  on  the  history  chart.  Several  postpartum  calls,  as  they  are 
termed,  may  thus  be  made  in  the  course  of  a  few  hours.  In  such  post- 
partum Avork  the  pu])il  acquires  a  knoAvledge  of  the  daily  changes  in  the 
lochia,  au}^  alteration  in  the  stump  of  the  umbilical  cord,  in  the  breasts, 
and  other  postpartum  phenomena  Avhich  is  of  quite  as  much  value  as  the 
management  of  a  case  of  normal  labor. 

Upon  his  return  to  the  Hospital,  the  pupil  is  required  to  report  the  condi- 
tion of  his  postpartum  cases  to  the  Kesident  Physician  or  his  representative. 


6-2  REPORT   OF   THE   SOCIETY    OF   THE    LVI^^G-IX    HOSPITAL. 

(h)  Indoor  o/-  ]fit/'(/  Pi'tictice. 

In  April,  1895,  systeinatic  instruction  in  the  care  of  the  piierpei'al 
woman  and  her  child  was  begun  in  the  wards  of  the  Hospital.  Each 
week  the  junior  j)upils  coming  on  duty  are  divided  into  three  equal  grou})s. 
Each  group  serves  on  ward  duty  for  t\vo  days,  and  during  this  time  is 
under  the  direct  supervision  of  an  assistant  resident  physician,  who  is 
detaikni  for  ward  duty.  Each  morning  the  grou])  on  duty  meets  the 
assistant  on  ward  duty  in  the  wards  of  the  iros])ital,  and  is  given 
]">ersonal  instruction  in  tlie  care  of  the  puerperal  woman  and  her  child. 
This  instruction  includes: 

1.  (Observations  on  the  general  condition  of  the  motluM- — her  tempera- 
ture. ])ulse,  resj)irations,  bowels,  bladder,  condition  of  breasts,  diet,  char- 
acter of  lochia,  ap})lication  of  binder  and  vulva  pad,  asepsis  and  antisepsis, 
and  any  complication  or  abnormality  that  may  be  present. 

'1.  Observations  on  the  general  condition  of  the  child — its  temperatui-e, 
]nilse.  and  respirations;  condition  of  stools,  bladder,  mouth,  nose,  eyes, 
breasts;  method  of  nursing,  dressing  of  stump  of  cord,  cleansing  of  mouth 
and  eyes,  and  api)licatiou  of  binder. 

E.   Obstetrical    Clinics,    Including    Nokmal     Labor    and    Obstetrical 

Surgery. 

The  equipment  of  the  o[)erating-room  and  amphitheatre  of  the  Hospital 
allows  of  each  normal  and  abnormal  delivery,  operation,  or  examination 
beinjj:  made  the  occasion  for  an  obstetric  clinic. 

The  rules  require  tliat  all  stall'  oiticers,  undergraduate  and  gi'aduate 
pupils,  and  nurses  shall  be  summoned  to  such  clinics. 

Tlicse  clinics  are  conducted  by  the  Attending  Physician  on  duty,  or  one 
of  the  resident  staff  officers,  and  are  made  to  take  the  nature  of  demon- 
strations. The  steps  of  the  examination,  delivery,  or  operation  are 
explained  and  enlarged  upon  by  the  lecturer,  and  in  abnormal  cases,  post- 
graduate ])upils  are  called  down  to  the  o])erating  table  to  examine  the  case. 

I-'or  these  obstetric  clinics  to  be  properly  carried  out,  it  is  necessary 
that  tiie  resident  staff  of  the  Hospital  shall  also  be  a  teaching  staff,  and 
that  a  preliminary  history  of  the  case  in  sucii  instances  shall  be  concisely 
statcMJ,  as  well  iis  a  careful  ex])osition  of  each  step  of  the  lal)or  or  opera- 
tive procedure. 

It  is  the  intention  of  the  .Mcdicnl  iJrcird  that  these  clinics  shall  evcutu- 
ally  resemi)le  the  diagnosis  chiss<'s  held  iibroad,  as  in  Munich  and  Prague. 
In  the  maternities  of  these  cities,  ])arturient  W(»iii('n  arc  bi'ought  into 
tlie  :imphitheatr(?  of  tiie  IIos])ital  fr(jiii  tlu^  ward  or  <l('iivery-ioom,  and 
two  students  arc  cidlcd  (h>wn  IVom  thcii-  scats  and  i-ecjuired  to  rcndei-  tlieir 
liands  and  forcwnns  obstetrical ly  clean  in  ihc  pi-csence  and  under  the;  criti- 
cism of  tluj  instructor,  examine  tlu^  case,  and  make  the  dingnosis  of  l)r(!g- 
nancy  or  labor,  j)resentation,  condition  of  the  os.  nienibi-nnes,  vagina, 
vulva,  i)ladd(?r,  and,  finally,  undergo  (jiicslioning  from  Ihc  instructor 
regarding  their  lindings  in  iIm;  case. 


PRACTICAL   INSTRUCTION   GIVEN   BY   THIS   HOSPITAL.  03 

Should  operation  or  interference  be  called  for,  it  is  performed  by  the 
instructor;  but  should  the  case  prove  a  normal  one,  the  student  will  be 
])ermitted  to  complete  the  case,  always  under  the  criticism  and  supervision 
of  the  instructor,  who  shall  be  expected  to  address,  not  only  the  students  at 
the  case,  but  the  entire  audience. 

Many  points  of  ])ractical  interest  connected  with  the  management  of 
the  second  and  third  stages  of  labor,  the  handling  of  the  child,  the  care 
of  its  eyes,  the  administration  of  the  postpartum  douche,  the  watching  of 
the  fundus  uteri,  the  application  of  the  occlusion  dressing  and  abdominal 
binder,  may  be  dwelt  upon  in  a  most  thorough  as  well  as  interesting  manner. 

Some  idea  of  the  scope  of  the  clinical  teaching  in  these  obstetric  clinics 
may  be  gathered  from  the  following  table,  which  indicates  that  from  Feb- 
ruary 18,  1895,  to  April  1,  1896,  two  hundred  and  fifty-six  (256)  clinical 
lectures  were  delivered  either  by  the  attending,  assistant  attending,  or 
resident  physicians  of  the  Hospital. 

Table  of  Clinical  Lectures  Delivered  up  to  April  1,  1896. 

Numher  of  Confinements    from   February  18,    1895,    to 

April  1,  1896 256 

Number  of  normal  delivery 130 

premature  births 45 

abortions 17 

forceps  delivery 22 

versions 8 

accouchement  force  and  version T 

accouchement  force 6 

craniotomy 3 

decapitation  (Barnes's  hook) 1 

symphysiotomy 1 

manual  extraction  of  breech 16 


Total 256 

Special  Graduate  Instruction, 
antepartum,  intrapartum,  postpartum,  operative. 

With  the  exception  of  certain  privileges,  the  intrapartum  instruction 
to  graduates  differs  little  from  that  given  to  the  undergraduate  pupil  by 
the  attending  physicians  and  resident  staff  of  the  Hospital. 

The  same  oversight,  the  same  checks,  the  same  supervision  are  brought 
to  bear  upon  the  work  of  the  former  as  well  as  upon  that  of  the  latter. 
The  general  Hospital  regulations  apply  to  him.  Cases  are  assigned  to  him 
in  regular  rotation  with  the  undergraduate  pupils,  but  with  this  privilege — 
that  he  may,  at  his  own  discretion,  forfeit  his  turn.  A  case  once  assumed, 
however,  must  be  carried  to  its  completion.     He  sends  in  to  the  Resident 


64  REPORT   OF   THE  SOCIETV    OF   TUF    LYING -IN    HOSPITAL. 

Physician  the  reguhii"  ropoi'ts  of  the  progress  of  the  cases;  he  fills  out,  in 
sending  in  word  of  complications  to  the  Hospital,  the  blank  ])rovided  for 
that  ])urpose,  and  is  not  allowed  to  interfere  without  i)ermission  of  the 
resident  or  attending  j)hysicians. 

The  privileges  tendered  the  graduate  consist,  Jirst,  in  the  fact  that  he 
may  select  his  cases;  and,  secondly,  he  is  pei-mitted  to  perform  sucli  opera- 
tions as  the  Attending  Physician  may  assign  him.  He  remains  one  month 
in  the  Hospital,  and  agrees  to  confine  at  least  fifteen  cases. 

The  Hospital  ofl:ers  two  s])ecial  courses  of  graduate  instruction,  as 
follows: 

A.   The  GRAorATE  Operative  Course. 

Physicians  entering  upon  this  course  of  instruction  are  expected  to 
reside  in  the  Hospital  building,  in  separate  apartments  set  apart  for  the 
purpose,  and  they  shall  during  their  term  of  service  be  subject  to  the 
Special  Hules  for  Graduate  Pupils,  and  also  to  the  General  Rules  of 
the  Hospital. 

This  course  includes  the  care  and  delivery  of  normal  cases,  and  the 
witnessing  of  all  the  operations  performed  in  tlie  service  of  the  Hospital, 
and  the  performance  of  such  obstetric  operations  by  the  pupil  as  the  Dii-ec- 
tor  may  assign  to  him,  and  each  pupil  shall  receive  at  least  one  obstetric 
o})eration  in  each  two  weeks  of  his  service. 

Pupils  in  this  course,  in  order  to  obtain  the  Certificate  of  the  Institu- 
tion, shall  attend  in  confinement  at  least  seven  patients  in  each  fortnight 
of  the  course,  and  they  shall  have  the  privilege  of  indicating  to  the  Resi- 
dent Physician  the  time  when  they  desire  such  cases  shall  be  assigned  to 
them.  But  once  having  undertaken  a  case,  they  shall  attend  it  until  dis- 
charged from  the  service, 

Ij.   Graduate  Diagnosis,  or  Touch  ('ourse. 

Physicians  taking  this  course  do  not  reside  in  the  Hos])ita]  building, 
but  each  afternoon  receive  instruction  in  the  ante})artuin  examining-room 
from  the  attending  or  assistant  attending  physician  on  duty. 

In  addition,  members  of  this  course  are  permitted  to  witness  all  opera- 
tions performed  in  the  service,  and  are  permitted  to  examine  such  abnor- 
mal cases  as  require  operation. 

The  fee  f(jr  the  above  course  of  two  \veeks  is  §20. 


THEORETICAL    LECTURES 


Demonstrations.  — Recitations. 

Although  the  Medical  Board  requires  that  students  shall  have  some 
theoretical  knowledge  of  obstetrics  before  taking  a  course  at  this  Hospital, 
a  certain  amount  of  theoretical  instruction  is  combined  with  the  practical 
instruction  given  in  the  clinics  and  at  the  bedside  in  the  tenements.  Obvi- 
ously, in  the  short  time  that  a  student  is  at  the  Hospital,  but  a  small  part 
of  the  more  important  subjects  can  be  taken  up  which  it  is  possible  to 
teach  in  a  theoretical  lecture.  Realizing  this,  the  Medical  Board  has  been 
compelled  to  limit  the  subjects  of  theoretic  instruction  mainly  to  the  man- 
airement  and  mechanism  of  normal  labor.  These  lectures  are  illustrated 
and  made  more  practical  by  the  ordinary  aids  to  didactic  teaching.  Dem- 
onstrations on  the  blackboard,  charts,  and  anatomical  preparations,  a  metal 
pelvis  which  is  mounted  on  a  tripod,  and  the  phantom  of  Schultze,  are  the 
aids  which  are  constantly  employed.  Wax  models  showing  the  anatomy 
of  the  generative  organs,  embryological  models,  and  wet  specimens,  and  a 
series  of  deformed  pelves  serve  to  illustrate  the  special  lectures  which  are 
given  bv  the  attending  physicians  whenever  cases  of  special  interest  occur 
in  the  service  of  the  Hospital. 

It  is  believed  that  more  practical  good  can  be  accomplished  by  didactic 
lectures  which  have  a  direct  bearing  on  the  work  in  hand,  than  by  any 
lecture  following  a  routine,  and  which  must  be  repeated  from  week  to  week 
as  each  new  set  of  students  come  on  duty.  In  short,  theoretic  instruction 
should  precede  and  follow  the  instruction  given  during  the  student's  Hos])i- 
tal  course,  when  he  is  gaining  that  practical  experience  and  self-reliance 
which  onlv  come  from  observation,  and  by  the  personal  examination  and 
care  of  women  during  pregnancy,  childbirth,  and  the  puerperium. 

Theoretic  instruction  by  didactic  lectures  is  given  under  the  supervision 
of  the  Medical  Board  by  the  attending  physician  on  active  duty,  and  by 
the  attending  ph3^sician  on  septic  duty.  The  Board  of  Assistant  Attend- 
ing Physicians  has  charge  of  the  recitations,  the  assistant  on  regular  duty 
reviewing  the  subject  matter  of  the  regular  lectures  and  the  work  in  the 
antepartum  rooms.  Instruction  is  also  given  by  the  house  staff.  This 
part  of  the  work,  however,  comprises  instruction  in  the  outdoor  service, 
and  is  described  elsewhere. 

The  lecture   given  by  the   attending   physician  is  called  the  regular 


66  REPORT   OF   THE   SOCIETY    OF   THE    LVING-IX    HOSPITAL. 

lecture,  and  is  delivered  early  in  tlio  course.     The  ground  covered  l)y  this 
lecture  is  summarized  as  follows: 

1.  Intnnhtvtori/. — A  short  ex})laiuition  of  the  i)rintcd  rules.  The  neces- 
sity of  discipline  in  Hospital  woi'k,  and  the  conduct  to  be  observed  in  the 
presence  of  patients.  The  rules  which  govern  the  student  in  the  Ilos[)ital 
are  read  by  each  man  before  beginning  his  service,,  and  are  appended  here. 

Rules  for  Undergraduate  J*ui'ils. 

I.  Each  pupil  shall,  before  going  on  duty,  pay  to  the  Chief  Cleric  the 
prescribed  fee,  and  will,  in  return,  receive  a  receipt  which  will  entitk^  him 
to  reside  at  the  Hospital  and  receive  the  regular  instruction  for  the  period 
of  two  weeks.  IStudents  or  graduates  wishing  to  remain  a  longer  or  a 
shorter  pei'iod  of  time  will  be  allowed  to  make  special  conti'acts,  subject 
to  the  a]>))roval  of  the  ^fetlical  lioard. 

'2.  Any  ])upil  wishing  to  leave  the  Hospital  before  his  allotted  term  of 
service  has  expired,  must  notify  the  Director  at  least  forty-eight  hours 
before  leaving. 

3.  Any  pupil  may  be  denied  the  use  of  the  Hospital  at  the  discretion 
of  the  Director. 

4.  All  ])upils  shall  be  under  the  direct  control  of  the  House  Physician. 

5.  No  pupil  shall  be  absent  from  the  Hospital  all  night,  except  in  the 
discharge  of  his  duty.  Pupils  shall  board  in  the  neighborhood  at  their  own 
exj:)ense.  They  shall  report  to  the  medical  clerk  upon  going  to  meals  and 
upon  returning. 

(».  Pupils  shall  be  assigned  cases  in  regular  rotation.  If  the  pupil  on 
turn  be  out  in  the  duty  of  the  Hospital  when  a  case  comes  in,  he  shall  lose 
the  case,  but  he  shall  not  lose  his  turn.  H",  however,  he  be  absent  on  his 
own  ])leasure,  he  shall  lose  both  the  case  and  his  turn.  A  case  thus  trans- 
ferred goes  to  the  pupil  next  in  the  order  of  rotation. 

7.  No  ))U])il  shall  be  present  at  any  labor  not  falling  to  him  in  turn, 
except  in  tiie  case  of  operations,  and  only  in  such  cases  as  the  Director 
shall  permit. 

8.  Each  pu]»i]  shall  visit  twice  (hiily,  or  oftener  if  necessary,  ])ost- 
partum  cases  assigned  to  him,  and  also  such  other  cases  as  the  House  Phy- 
sician shall  direct.  He  shall,  at  these  visits,  observe  the  strictest  antisepsis, 
and  shall  i-e))ort  after  each  visit  the  jiatient's  conditicm  to  the  assistant 
resident  ])hysician  on  septic  and  history  duty,  or  in  his  absence  to  the 
ine<Jical  clerk. 

\).  All  ])U|)ils,  on  returning  from  a  case,  shall  immediately  make  the 
entry  of  their  notes  upon  the  ])ro])er  blanks  ])rovid(Ml  by  the  Hospital. 

10.  No  ])upil,  whil(!  in  pisrformance  of  his  duties,  shall  advise  or  ))i-e- 
scribe  for  any  ])atient  who  may  apply  to  him. 

II.  \o  pupil  shall  perform  any  obstetric  o|)eration,  nor  interfere  with 
any  mal-presentation,  nor  give  an  intrauterine  douche.  If  he  deem  such 
interference  necessary,  he  shall  send  iiiiincdiately  to  the  Hospital  for  assist- 
ance. 


THEORETICAL   LECTURES.  07 

1 2.  Pupils  shall  be  furnished  by  the  Hospital  Avith  clinical  thermome- 
ters, tape  measures,  locker  keys,  and  stethoscopes  on  receipt  of  the  pre- 
scribed deposit.  Pupils  shall  be  responsible  for  tlie  return  of  these  articles 
in  ii'ood  condition. 

13.  Pupils,  when  sending  to  the  Hospital  for  help,  shall  invariably  fill 
out  the  blanks  })rovided  for  that  purpose,  being  particular  to  note  the  time 
and  reason  for  sending. 

14.  Pupils  shall,  at  the  discretion  of  the  Director,  be  isolated  from 
attending  normal  cases  of  labor,  to  attend  any  septic  case  that  may  arise. 

15.  No  pupil  shall  receive  personal  remuneration  from  a  patient  under 
any  circumstances. 

16.  Each  pupil  shall,  before  going  on  duty,  deposit  with  the  Chief 
Clerk  the  sum  of  ten  dollars  as  security  for  the  cost  of  keys,  thermometer, 
tape  measure  and  stethoscope,  and  as  a  guarantee  that  he  will  serve  his 
full  fourteen  days.  This  deposit  will  be  forfeited  in  case  the  pupil  leaves 
or  is  dismissed  before  the  end  of  his  full  term  of  service.  Any  pupil  may 
be  dismissed  by  the  Director,  subject  to  the  approval  of  the  Medical  Board. 

IT.  Pupils  shall  serve  for  a  term  of  two  weeks  from  9  o'clock  in  the 
morning  on  the  date  of  appointment  until  12  o'clock  noon  on  the  fifteenth 
day  thereafter,  or  until  they  shall  have  made,  reported,  and  recorded  their 
postpartum  calls  for  that  day. 

18.  Each  pupil  at  the  termination  of  his  service,  provided  he  shall  have 
performed  his  duties  faithfully,  and  for  the  full  time  of  his  appointment, 
to  the  satisfaction  of  the  Medical  Board  and  of  the  Governors,  may  receive 
from  them  a  certificate  thereof. 

2.  The  Examination  of  Pregnant  Women. — The  methods  of  examina- 
tion are  taken  up  and  described  with  the  aid  of  the  Pregnancy  Sheet, 
which  is  printed  in  connection  with  the  description  of  the  methods  of 
keeping  statistics.  Students  are  taught  to  make  observations  and  to  record 
them  systematically.  The  ordinary  symptoms  of  pregnancy,  the  suppres- 
sion of  menses,  date  of  quickening,  and  the  methods  of  calculating  the 
probable  date  of  confinement  are  discussed. 

3.  The  Manageinent  of  Labor  is  described,  using  the  charts  as  a  guide. 
The  methods  of  diagnosis  of  presentation  and  position,  particularlv  by 
abdominal  palpation;  the  diagnosis  of  the  existence  of  labor  and  the 
mechanism  of  normal  labor  are  referred  to;  it  being,  however,  supposed 
that  the  student  has  some  previous  knowledge  of  this  part  of  the  subject. 

The  division  of  labor  into  stages  having  been  explained,  the  manage- 
ment of  each  stage  is  in  turn  taken  up  and  described.  The  greater  part  of 
the  time  is  used  in  the  explanation  of  the  principles  of  preserving  the  peri- 
neum from  rupture  and  illustrating  these  on  the  phantom.  The  proper 
management  of  the  placental  stage  is  minutely  described,  and,  finally,  the 
care  of  the  mother  and  child  subsequent  to  labor.  The  manual  pressure 
on  the  uterus  as  a  guard  against  postpartum  hsemorrhage,  the  application 
of  the  binder,  the  cleansing  of  the  child's  eyes  and  mouth,  and  the  ordi- 
nary methods  of  establishing  respiration,  all  form  a  part  of  the  lecture. 


68  REPORT   OF  THE   SOCIETY   OF   THE   LYIXG-IX   HOSPITAL. 

4.  The  Oi'dinio'i/  CompUcatioihs  of  normal  labor  are  referred  to,  and 
the  printed  sheet  used  in  sending  for  assistance  is  shown. 

[it)  Delayed  labor,  with  its  causes,  in  the  various  stages; 

{h)  Ketained  i)lacenta  or  membranes; 

{c)  Lacerations  of  the  genital  tract;  and 

{(I)  Haemorrhage,  are  each  taken  and  described. 

Excepting  in  the  case  of  haemorrhage,  treatment  is  not  touched  upon, 
the  tlirections  being  that  the  student  send  at  once  to  the  Hospital  for 
assistance.  In  the  case  of  luiMnori-hage,  and  while  waiting  for  assistance, 
the  use  of  the  douche  and  the  other  methods  of  securing  contraction  of  the 
uterus  are  explaineil. 

.").  Pofttjnirtum  Visits  and  the  DaUij  Records  of  Mother  and  Child. — The 
ro\itine  treatment  and  observations  to  be  made  at  these  visits  are  taken  up 
in  connection  with  the  histor}"  charts. 

'■'.  Denionstrations  of  Abnormalities  or  Ojferatimis  of  the  Past  WeeJi. — 
This  forms  a  very  important  and  constantly  varying  part  of  the  lecture, 
and  covers,  from  time  to  time,  almost  the  whole  subject  of  dystocia  and 
obstetric  surgery.  On  the  phantom,  versions  or  forceps  operations  are 
I'epeated,  the  indications  for  o]ierating  ex])lained,  and  the  technique  illus- 
trated. It  may  be  added  that  at  the  conclusion  of  this,  the  regular  lecture, 
the  students  are  encouraged  to  ask  questions,  thus  bringing  the  lecturer 
more  closely  in  touch  with  the  class. 

The  Septic  Lectures, 

On  the  following  day,  or  as  soon  after  the  regular  lecture  as  possible,  a 
lecture  is  given  In'  tlie  sciatic  attending  physician.  This  lecture  is  also 
didactic,  and  may  be  summarized  as  folloAvs: 

1.  Antisepsis  in  ]al)or. 

a.  Sterilization  of  the  hands  and  forearms. 
h.   Sterilization  of  tlie  patient. 

e.   Sterilization    of    the   dressings    and    everything    whicii    may    be 
brought  in  contact  with  the  patient. 

2.  Tlie  nature  and  causes  of  ]iuer])eral  fever.  The  ordinary  sources 
tlirougli  whicli  a  ])atient  may  be  intV'ct(Ml,  and  the  prevention. 

?>.  The  classification  of  puerpcial   fever. 

4.   Sym])tomatf)l()gy  and  dijignosis  (jf  the  various  forms. 

.").   The  treatiiK'Hl  of  ])U(')'[)eral  bnei-. 

a.   Use  of  thf  douche. 

h.    Use  of  the  cni-cttc 

c.    Various  oj)erations. 
0,   F'ever  due  to  causes  other  thmi  iiilccl  ion. 

a.   Frrmi    the   digestive    ti-act.       Care   of   the    bowels,   and   use   of 
cathartics. 

h.  Care  of  the  breasts. 

c.   Other  conqdications,  causing  rise  in  tcnqierature. 


THEORETICAL    LECTURES.  69 

7.  The  necessity  of  antisepsis  during  the  puerperium.     Vulva  dressings. 

8.  The  necessity  of  cleanliness  and  antisepsis  in  nursing. 
a.  Care  of  the  nipples. 

h.  Care  of  the  chikrs  mouth. 

9.  Abnormalities  of  the  breasts. 
a.  Flat  or  deformed  nipples. 

h.  Ei'oded,  fissured,  and  cracked  nipples. 

c.  Painful  distention,  and  so-called  caked  breasts. 

d.  Mammary  abscess. 

10.  The  necessity  of  antisepsis  in  dressing  the  umbilical  cord. 

a.  Disinfection  of  the  cord,  and  materials  for  antiseptic  dressings. 
h.  Separation  of  the  cord,  and  dressings  for  the  stump. 

c.  Purulent  umbilicus:  its  treatment,  and  sepsis  in  the  child  (fever). 

d.  Icterus  in  the  child. 

11.  The  necessity  of  antisepsis  in  the  care  of  the  child's  eyes. 
a.  Crede's  method  of  using  nitrate  of  silver. 

h.  Frequent  washings  with  boracic  acid. 

G.  Ophthalmia  neonatorum :  its  causes,  symptoms,  and  treatment. 

The  regular  and  septic  lectures  comprise  all  the  didactic  teaching  given 
by  the  Medical  Board.  Although  the  lecture  is  theoretic,  it  is  based  each 
week  mainly  upon  clinical  grounds,  having  for  its  prominent  subject  cases 
which  have  actually  been  seen  by  the  students. 


Recitations. 

Toward  the  end  of  the  student's  first  week  of  service,  a  recitation  is 
held  b}^  the  assistant  attending  physician  on  duty.  As  has  already  been 
stated,  these  recitations  are  based  upon  the  subjects  of  the  regular  and 
septic  lectures.  They  include,  also,  questions  upon  the  antepartum  work 
and  outdoor  work.  Even  at  the  risk  of  needless  repetition,  a  synopsis  of 
the  recitation  is  also  made. 

1.  Antepartum  work. 

a.  Signs  of  pregnancy. 

h.  Methods  of  phj^sical  examination. 

c.  Diagnosis  of  presentation  and  position. 

2.  Labor. 

a.  Diagnosis. 

h.  Mechanism  of  vertex  cases. 

c.  Management  of  the  three  stages. 

3.  Postpartum  work. 

a.  Dressings  and  the  care  of  mother. 
h.  Visits,  temperature,  pulse,  etc. 
c.  Care  of  child. 


70  REPORT   OF   THE   SOCIETY   OF   THE    LYING  IN    HOSPITAL. 

4.  C'om[)licatioiis. 

<i.  In  pregnancy. 

h.   In  labor. 

c.  In  the  puerjieriuni. 

5.  Sepsis  and  antisepsis. 

Fiiuillv,  it  will  lie  seen,  that  although  the  student  is  supposed  to  be 
familiar  with  obstetrics  to  a  certain  extent,  still  a  large  part  of  the  theory 
is  taught  by  this  method;  the  lectures  and  recitations  ser\'ing  as  a  review, 
so  that,  in  the  ])rac-tical  ex]ierience  that  is  acquired  by  a  course  in  the  Hos- 
pital, the  theoretical  ]mrt  of  the  subject  is  kept  constantly  in  mind. 


THE   INSTRUCTION   OF   NURSES. 


It  has  seemed  to  the  Medical  Board  of  this  Hospital  that  the  system  of 
instruction  as  carried  out  in  the  Nurses'  Training  Schools,  with  which  we 
are  sufficiently  familiar  to  make  it  proper  for  us  to  judge,  was  susceptible 
of  improvement  in  certain  particulars.  Without  assuming  to  criticize  the 
methods  adopted  by  any  school,  we  believe  that  the  error  has  been  com- 
mitted of  teaching-  the  nurse  too  much  theoretical  medicine.  Lecturers 
and  classroom  instructors  in  training  schools  seem  to  look  upon  the  pupil 
nurse  much  as  they  look  upon  the  medical  student.  Their  lectures  and 
their  questions  differ  little  from  those  adapted  to  the  medical  student  in  the 
early  years  of  his  study.  Why  should  the}^  insist  that  the  nurse,  whose 
knowledge  of  physiology,  anatoni}^,  and  materia  medica  is  quite  elemen- 
tary, should  learn  pathology,  symptomatology,  and  treatment  of  disease 
with  as  much  accuracy  and  in  as  much  detail  as  the  medical  student  ? 
Would  it  not  be  wiser  to  teach  nurses  just  enough  of  the  theoretical  parts 
of  the  subjects  upon  which  the}^  are  working  to  make  it  possible  for  them 
to  do  their  work  intelligently  ? 

Moreover,  nurses  are  often  forced  to  do  so  much  arduous  manual  labor 
in  the  course  of  their  daily  work,  that  they  are  in  no  condition  of  mind  or 
body  to  study  during  the  time  when  their  ward  work  does  not  occupy  their 
attention.  If,  therefore,  it  is  deemed  Avise  to  require  nurses,  in  addition  to 
their  trying  bedside  work,  to  do  much  of  the  work  of  an  orderly,  they 
should  not  also  be  expected  to  commit  to  memor}^  medical  facts  which  are 
almost  unintelligible  to  them. 

It  is  to  be  remembered  that  this  Hospital  does  not  maintain  a  nurses' 
training  school.  It  simply  furnishes  obstetric  training  to  the  nurses  of 
other  hospitals.  In  so  far,  however,  as  it  is  possible,  in  this  limited  field, 
it  has  been  the  aim  of  the  Board  to  embody  its  ideas  on  the  subject  of 
nurses'  training  in  the  course  herein  described.  It  has  attempted  to  limit 
the  theoretical  teaching  of  its  nurses,  as  indicated  above,  and  to  make  it 
possible  for  them  to  do  whatever  stud3^ing  may  be  necessar}^,  without  over- 
taxing both  mind  and  body.  At  present  the  bedside  work  of  the  nurses  is 
limited  to  the  indoor  service  of  the  Hospital.  It  is  hoped  at  some  future 
time  to  utilize  the  outdoor  service  as  well,  but  as  yet  no  feasible  plan  has 
been  devised.  The  nurses  of  the  Hospital  are  derived  from  two  sources : 
the  Training  Schools  of  St.  Yincent's  Hospital  in  this  city  and  of  St.  Mary's 


72  REPORT  OF  THE   SOCIETY   OF   THE   LYING-IN    HOSPITAL. 

Hospital  ill   r>i-u(.)klyn.     Those  mirses  come  to  the  Jlospital  in   the  latter 
part  of  tlieir  coui*se  of  training  for  a  period  of  three  months. 

The  niirsin*:  department  of  the  Hospital  is  in  charge  of  the  Chief 
Nurse  and  her  Assistant.  The  Chief  Nurse  is  in  absolute  control  of  her 
dei)artment,  both  as  to  the  disposition  of  the  work  among  her  nurses,  and 
as  to  mattei*s  of  disci])line,  and  she  is  responsi])le  and  answerable  to  the 
Meilical  IJoard  only.  The  course  of  instruction  may  be  outlined  as 
follows: 

1.   Theoretical: 

Lectures. 

Classroom  recitations. 
1'.    Practical: 

( )utdoor  I)ej)artment — Laboratory. 

( )utdoor  l)ej)artment — ( )l)stetrical  examinations. 

Indoor  Department — AVard  work. 

Indoor  Department — Operating-room. 
1.   Lictiii'is. — This  part  of    the  instruction  has  been  deputed   l)y    the 
Medical  Board  to  the  Assistant  Attending  Physicians.     The  lectures  extend 
over  a  ])eriod  of  two  months,  and  are  delivered  weekly  ])y  the  assistant 
attending  [)hysician  on  duty. 

OiTLixE  OF  Lectures  to  Nueses. 

1.  Gross  Anatomy  and  Physiology. 

'1.   Pregnancy,  signs:  labor,  mechanism,  ])resentation,  phenomena. 

3.  Cleanliness,  sepsis,  bacteriology. 

4.  A})plication  of  cleanliness:  methods. 
."».   Pre])aration. 

«;.  Care  of  woman,  antepartum  and  })ostpartum. 

7.  Care  of  child. 

8.  Emergencies;  relation  of  nurse  to  doctor. 

LECTURE    I. 

Gross  Anatomy 

of  Female  Pelvis. 

Genitalia  and  pelvis. 

False  and  true. 

Brim  and  outlet. 

Bones. 
Soft  Parts. 

Urethra.  l)l;i(ld<>r.  ui-eters,  Icidneys. 

Rectum. 

Vagina,  uterus,  tubes,  ovaries. 

Vulva,  clitoris,  meatus,  ostium  vagina;. 

Anus. 

Perineum. 

Abdomen. 


THE   INSTEUCTION    OF   NURSES.  73 

Gross  Physiology 

of  Female  Genitalia. 

Puberty  and  menopause,  menstruation. 

Ovulation. 

Impregnation  and  development  of  foetus. 

Parturition,  abortion. 

Puerperium. 

Urinary  system;  excretory. 
Gastro-intestinal ;  alimentary  and  excretory. 

LECTUEE    II. 

Pregnancy. 
Signs. 

a.  Subjective. 
h.  Objective. 
Mechanism. 

Signs  of  beginning  labor. 

First  stage:  dilation  of  cervix. 

Character  of  pains. 
Second  stage:  expulsion  of  child. 

Character  of  pains. 
Third  stage:  expulsion  of  placenta. 
Presentation. 
Yertex. 
Breech. 
Shoulder. 

Prolapse  of  umbilical  cord. 
"  "  Arm  and  hand. 
"         "  Leg  and  foot. 

LECTURE    III. 

Cleanliness. 
Importance. 

Asepsis  and  antisepsis. 

Auto-infection  (?)  and  ex-infection. 
Origin. 

Clothing,  skin,  catheter,  rectum. 

Patient's  hands,  physician's  hands,  nurse's  hands. 

Bedpans,  daily  dressings,  neighboring  erysipelas,  pneumonia,  sore 
throat,  child's  eyes  and  navel. 
Bacteriology. 

Staphylococci. 

Streptococci. 

Gonococci. 

Colon  baciUi. 
Immunity. 


74  REPORT  OF  THE   SOCIETY   OF  THE   LYING-IN   HOSPITAL. 


LECTURE   IV. 

Principles  and  Aj^plication 
of  cleiinliness  to 

(a)  Instriinients  and  apparatus. 

Dressiniis,  vulva  pads,  bandages,  etc. 
Bed  clothing. 

Dress  of  nurse  and  physician. 
{h)  Kui'se  and  physician. 
Disinfection:  hands,  nails. 
Care  of  hands. 
A^aginal  examination. 
Use  of  vaseline. 
Method  of  introducino-  hnffer. 
External  examination. 
Methods  of  securing  asepsis  in  private  houses  in 
{a)  City,  with  conveniences. 
(h)  Country,  with  no  conveniences ;  old  linen,  wash  boiler. 

LECTURE    v. 

Preparation  for  Labor. 
Body. 

Attention  to  bladder,  rectum,  nervousness,  feeding,  clothing,  baths, 
flannel  drawers,  hair  braided. 
Bed  and  Iloom. 

Temperature  of  room,  seventy-three  degrees  or  more. 

Boom  cleansed  and  plain. 

Hair  nuittress  ])referred. 

Karrow  bed. 

Bubbei-  sheeting,  absorbent  pad. 

Old  (juilt,  sheets  in  ]ilenty,  old  blanket,  sterilized. 

Sheet  fastened  to  foot  of  bed  to  grasp. 
Prepai'ation  of  supplies. 
Prepai-ation  of  nurse. 

Toward  liousehold,  doctor,  and  patient. 

Removal  of  placenta  and  blood. 

LECTURE    VL 

Care  of  AVoman. 
Antepartum. 

liowels,  liladder. 

Comfort;  varirosities,  pendulous  abdomen  or  l)reasts,  l)reathing. 
Feeding. 

Allay  nervousness. 

Watch  for  mental  changes;  mania,  melancholia,  headache,  blindness, 
cedcma,  vomiting,  iiiiiu!. 


THE   INSTRUCTIOiSr   OF   NUfiSES.  75 

During  Labor. 

That  patient  is  not  exposed. 

Catching  cold. 

Is  clean. 
Postpartum. 

Catheterization. 

Urine:  relaxation,  haemorrhage. 

After  pains. 

Lactation,  feeding. 

Pulse,  temperature,  breathing. 

Caked  breasts,  fissured  nipples. 

Constipation. 

Fever,  douches. 

Involution  and  lying  in  bed. 

LECTURE   VII. 

Care  of  Child. 
Washing. 

Yernix  caseosa. 

Oil,  soap,  sponge,  temperature  of  bath,  baby  powder,  frequency. 
Clothing. 

Cloths  for  navel. 

Binder,  flannel  slips,  napkins,  etc. ,  stockings. 
Feeding. 

Size  of  child's  stomach,  frequency. 

Weigh  weekly. 
Sleep. 

Surrounding  temperature. 

Cry. 

IS^ormal  injuries  during  delivery. 

Shape  of  head,  cephalhsematoma. 

Discolored  face. 
Observe : 

Genitals,  anus,  and  deformities,  cleft  palate,  hare  lip,   tongue-tie, 
talipes. 
Eyes. 

Ophthalmia. 
Mouth. 

Thrush. 
Yomiting,  colic,  diarrhoea,  constipation,  descent  of  bowels,  worms. 
Petention  of  urine  and  fgeces,  incontinence. 
Bleeding  from  the  navel,  from  bowel. 
Icterus  (no  change  in  urine  or  faeces  or  eyes). 

Naevi  and  eruptions,  burns  and  scalds. 

Atelectasis. 

Swelling  of  breasts. 

Convulsions. 


76  REPORT  OF  THE   SOCIETY   OF   THE   LYIXG-IN   HOSPITAL. 

Care  of  CliiUl. 

Icterus  (no  cliange  in  urine  or  fjeces  or  eyes). 
Bruises,  s])rains,  fractures,  outs. 

Stings  of  insects,  foreign  bodies  in  eyes,  ears,  nose,  and  throat. 
Bleeding  from  nose,  earache,  fever. 
Prenuiture  chiklren. 


LECTURE   VIII. 


Emergencies. 

Delivery  if  doctor  does  not  arrive. 

Holding  back  liead  and  delaying  labor  until  arrival  of  doctor. 
Ante})artuui. 

Kephritis,  eclam])sia,  mania,  haemorrhage,  placenta  prgevia. 

Abortion  or  miscarriage. 
At  Lal)or. 

Operations,  perineorraphy,  etc. 

Haemorrhage. 

Prolapse  of  cord. 
Postpartum. 

Ila^mori'liage. 
.    After  pains. 

Mania. 

Caked  breasts  and  abscesses. 

Fever. 

Sickness  of  mother  or  child. 
Tact  in  calling  doctor. 
Relation  of  nurse  to  doctor  and  to  ])atient  and  to  patient's  household. 

Clasifrooiii  Worl-. — The  classroom  work  is  carried  on  by  the  chief  nurse. 
She  holds  recitations  weekly  upon  subjects  prescribed  by  the  Medical 
Board.  These  subjects  have  reference  to  the  lectures  of  the  assistant 
attending  physician  and  to  the  ward  work  of  the  nurses.  In  the  instruc- 
tion of  the  nurses,  as  well  as  of  students,  it  is  the  purpose  of  the  Board  to 
confine  the  attention  of  their  ])U])ils  to  tlioii*  ])vactical  work  as  a  source  of 
study  i-atbcr  than  to  text-books. 

II.  ( hiidi, (I r  Department. — {<i)  J.iih(ir<il<>/'i/  Worl-. — Th(»  woi-k  under  this 
heading  (insists  in  the  ])i"opai'ation  and  care  of  tlie  material  and  ])ai'a- 
])liernalia  in  use  in  the  outdoor  depai-tnicnt  of  the  Hospital,  a-nd  it  is  the 
first  work  to  wliicli  the  nurse  is  assigned.  Two  nurses  are  on  duty  at  the 
sjime  tiiMf;  in  this  i-ooni,  and  the  term  of  service  is  two  wecH-cs.  Praxttically 
all  of  the  woi-k  is  done  (hii-ing  the  day  hours,  so  tliat  these  nurses  are  rarely 
called  at  night. 

The  following  is  an  outline  of  their  work  in  tliis  de])artment: 

l*(j8tpai'tuin.  and  Labor  BaijH. — Every  case  of  labor  in  the  outdoor 
sen'ice  necessitates  the  use  of  a  labor  bag,  and  every  student  in  the  Hospi- 
tal uses  two  j)ostpartum  bags  (hiily  in  making  his  cmHs.      In   addition  the 


THE    INSTRUCTION"   OF   NURSES.  77 

staff  make  use  of  a  considerable  number  of  bags  in  the  course  of  their 
work.  It  is  the  duty  of  the  nurses  to  clean  and  fill  these  bags  after  their 
return  from  service  in  the  tenements.  To  facilitate  the  work,  a  list  of 
articles  which  should  be  found  in  each  bag  is  pasted  on  the  inside  of  the 
cover.  These  lists  can  be  found  in  the  portion  of  this  article  treating  of 
the  subject  of  practical  instruction  to  students,  and  a  perusal  of  their  con- 
tents will  convey  a  better  idea  of  the  practical  value  of  this  work. 

Ytdva  Di'essings. — The  nurses  are  also  obliged  to  prepare,  with  the  aid 
of  helpers,  all  the  dressings  in  use  in  the  out-patient  dej^artment.  The 
heavy  work  of  the  laboratory,  such  as  cutting  the  gauze  and  cotton  for  the 
vulva  pads,  is  done  by  an  orderly.  These  dressings  are  then  enclosed  in 
cop])er  receptacles  having  perforated  caps  at  both  ends,  and  sterilized. 

Instruments. — All  instruments  in  use  in  this  department  are  cleaned, 
sterilized,  and  again  prepared  for  service  by  the  nurses.  It  will  thus  be 
seen  that  everything  having  to  do  with  the  preparation  and  care  of  the 
material  and  paraphernalia  of  the  labor  and  postpartum  rooms  becomes 
familiar  to  the  nurse  before  her  admission  to  the  wards  and  operating- 
room. 

(b)  Ohstetrical  Examinations. — During  their  period  of  service  in  the 
laboratory  of  the  outdoor  department,  the  nurses  are  required  to  spend  as 
much  time  as  may  be  necessary  daily,  except  Sunday,  in  the  examining- 
rooms.  They  are  here  under  the  supervision  of  the  assistant  to  the  chief 
nurse  and  one  of  the  assistant  attending  physicians.  They  learn  the  man- 
ner of  preparing  a  patient  for  an  antepartum  examination,  and  the 
manner  of  conducting  the  examination  easily  and  with  as  little  annoyance 
as  possible  to  both  patient  and  physician. 

Indoor  Department. —  Ward  Work. — Each  nurse  is  on  day  duty  for 
four  consecutive  weeks,  and  on  night  duty  for  four  weeks.  The  day  nurses 
relieve  the  night  nurses  at  seven  o'clock  in  the  morning,  and  are  relieved 
by  the  night  nurses  at  seven  o'clock  in  the  evening. 

Briefly  rehearsed,  the  ward  work  consists  in  noting  pulse  and  tempera- 
ture; in  performing  the  necessary  daily  dressings  of  breasts  and  genitals, 
including  the  application  of  the  binders  to  both  breasts  and  abdomen;  in 
administering  food  and  medication;  in  the  bathing  and  dressing  of  the 
infant,  and  its  application  to  the  breast ;  in  noting,  for  purpose  of  report, 
the  character  of  the  lochia,  the  stools  and  the  breasts  of  the  mother,  and 
the  skin,  mouth,  umbilicus,  eyes,  and  stools  of  the  child.  They  are  also 
taught  methods  of  stuj^ing  breasts  and  abdomen,  the  administration  of 
the  vaginal  douche,  and  the  use  of  the  catheter  in  postpartum  women. 
Incidentally,  they  have  considerable  practice  in  keeping  obstetric  records 
according  to  fixed  forms. 

The  nurses  are  present  at  rounds  in  the  morning,  and  hear  the  clinical 
teaching  of  the  medical  officer  in  charge  of  the  instruction  of  the  students. 
In  the  course  of  her  ward  service,  a  nurse  may  at  any  time  be  isolated  for 
the  care  of  a  septic  case,  or  detailed  for  special  service  upon  some  operative 
case  of  unusually  serious  character. 

Operating-room  Work. — The  Hospital  at  present  has  no  special  corps 


78  REPORT   OF   THE   SOCIETY   OF  THE   LYING-IN   HOSPITAL. 

of  o]ierating-room  nui*ses,  and,  therefore,  this  work  is  included  in  the  ward 
service. 

Tlie  operating-room  is  in  use  daily  for  the  ]nir]iosc  of  normal  deliveries, 
at  whicii  one  or  more  nui'ses  are  in  constant  attendance.  .Vpart  from  her 
own  work  at  this  time,  the  nurse  hears  the  instruction  given  to  the  stu- 
dents, and  she  must  necessarily  ohtain  valual)le  information  therefrom. 
Each  lalfor  is  the  suigect  of  a  continual  clinical  lecture,  and  quite  often 
these  lectures  are  given  by  the  attending  and  assistant  attending  physicians. 

In  the  absence  of  both  the  attending  j)liysician  and  his  assistant,  it  is 
the  duty  of  the  house  physician,  or  the  mendjer  of  the  statf  on  ward  duty, 
to  give  this  instruction. 

Here  she  is  trained  in  her  duties  as  an  assistant  to  the  accoucheur  dur- 
ing normal  labor  and  during  oi)erative  procedures,  and  sees  constantly  the 
administration  of  chloroform  and  ether. 

^lethods  of  making  vaginal  examinations  are  taught  during  the  first 
and  second  stages  of  labor,  so  that  the  nurse  is  competent  to  give  an  intel- 
ligent and  reliable  report  of  the  condition  of  the  cervix  and  the  mem- 
branes, and  of  the  position  of  the  presenting  ]iart  relative  to  the  perineum. 
She  learns  also  how  to  "  strip  "  and  tie  the  umbilical  cord,  and  care  for  the 
new-born  infant,  as  well  as  methods  of  resuscitation  of  an  asphyxiated 
child.  The  manner  of  holding  the  uterus  through  the  abdominal  wall 
before  and  after  the  expulsion  of  the  placenta  is  also  explained.  In  short, 
every  procedure  whicli  is  carried  on  in  the  delivery-room  becomes  thor- 
oughly familiar. 

It  is  also  to  be  remembered  that  many  of  the  most  serious  operative 
cases  of  the  outdoor  service  are  l)rought  to  this  room  for  operation, 
making  tlie  operative  service  unusually  large.  The  rule  in  such  cases  is 
that  all  the  nurses  not  on  duty  are  summoned  to  the  operating-room  to 
witness  major  operations.  During  the  course  of  an  operation,  the  nurses 
on  duty  in  the  operating-room  have  certain  specific  duties  assigned  to  them 
under  tlie  charge  of  the  assistant  to  the  chief  nurse.  By  rotating  the 
nurses  from  one  set  of  duties  to  another  in  the  operating-room,  they 
become  familiar  with  every  phase  of  the  w^ork  of  preparation  and  assist- 
ance. Each  nurse,  also,  during  her  ward  service,  has  sole  charge  of  the 
delivery-room  during  a  certain  number  of  normal  deliveries.  She  thus 
learns  by  constant  practice  the  actual  performance  of  the  nurse's  duties  in 
the  lying-in  room,  both  in  normal  and  operative  cases;  and,  finally,  while 
in  charge  of  the  operating-room  she  assumes  the  res])onsibilities  of  an 
important  position  which  slici  iriust  fill  afterwards  in  private  jn-actice,  while 
she  is  still  under  supervision,  and  where  her  (M-rors  can  be  pointed  out  and 
remedied. 

It  would  sr-em  that  such  a  cours(!  of  1r;iiniiig,  conscientiously  adminis- 
tere<l,  would  give  the  nurse  a  thorough  preparation  for  her  obstetric  work. 


STATISTICAL  SYNOPSIS. 
By  H.  McM.  Painter,  M.D. 


The  following  statistical  report  covers  a  period  of  six  years  and  three 
months,  from  the  foundation  of  the  Midwifery  Dispensary  to  April  1,  1896. 
It  will  be  noted  that  the  cases  of  the  outdoor  department  only  are 
included  in  this  report. 

The  disparity  which  will  be  noticed  under  all  headings  between  the 
number  of  cases  in  the  service,  10,233,  and  the  number  of  observations 
recorded,  is  explained  by  the  fact  that  in  a  service  of  this  character  there 
are  many  cases  in  which  it  is  impossible  to  obtain  the  desired  information ; 
in  some  cases  there  is  no  record  to  be  made;  e.g.,  presentation,  sex,  pla- 
centa, etc. ,  in  cases  of  abortion ;  etc. 

Applications 12, 802 

Confinements 10,233 

Living  children    9,457 

Still  births 359 

Abortions 41T 


10,233 


Nativity, 


United  States 910 

Germany 422 

Russia 6,885 

Poland 257 

Ireland 342 

England 123 

Austria 751 

Roumania 138 

Hungary 174 

10 

4 

9 

22 

1 

1 


Scotland  . . . . 

Holland 

Switzerland . . 
Italy 

Egypt 

Isle  of  Jersey 


Palestine  . . . 
Bohemia  . . . 

Wales 

Arabia 

Canada 

France  

Nova  Scotia 
Finland  .... 
Turkey  .... 
Australia . . . 
Sweden  .... 
Armenia  .  . . 
Unknown  . . 


1 

2 
1 

2 
6 
2 
1 
2 
2 
1 
6 
1 
159 


Total 10,233 


80 


REPORT  OF  THE  SOCIETY   OF  THE   LYING-IN   HOSPITAL. 


Civil  Condition. 

Married 10,182 

Single 8 

Widowed 12 

Unknown 31 


Total 10,233 

Age. 


15-20  years 943 

20-25  '  "      3,670 

25-30     "     3,088 

30-35     "      1,485 

35-40     "     ,....  821 


40-45  years 104 

45-50     ''      13 

50-55     "     1 

Unknown 98 


I. 
II. 

TIT. 
IV. 

V. 

YT. 

VII. 

VIII. 

IX. 

X. 

In 
cases. 


para 


Para 

Cases. 
2,157 
1,901 
1,566 
1,228 

939 

724 

557 

389 

249 

171 


Total 10,233 

Cases. 

79 

70 

38 

16 

8 

1 

1 

139 


XII. 

r 

XIII. 

XIV. 

XV. 

XVII. 

XX. 

Unknown 

Total 

Presentation. 
the  10,233  cases  it  was  possible  to  observe  the  presentation  in  8,969 


No.  of 
Cases. 

Ratio. 

CHILDREN. 

Died  during 

Presentation. 

Living. 

Still-born. 

211 

8»; 
24 

3 

0 

1 

325 

34 

359 

the 
Puerperium. 

Vertox 

8,495 

341 

91 

36 

4 

2 

1  in  1.05 
1  in  26.30 
1  in  98.56 
1  in  249.13 
1  in  2242.25 
1  in  44.S4.50 

8,284 

255 

67 

33 

4 

1 

149 

Breodi 

Slioulder 

Face 

35 
2 
3 

Prow 

0 

Kar  

0 

8,969 
847 
417 

8,644 

189 

Presentation  not ) 

obscrv(*d f 

Abortions 

813 

25 

Total 

10,233 

9,457 

214 

statistical  synopsis.  81 

Displacement  of  Fcetal  Parts. 

With  regard  to  the  following  table,  it  must  be  stated  that  only  those 
cases  are  included  in  which  the  displacement  occurred  spontaneously.  If 
the  extremities  or  the  funis  became  displaced  during  some  manipulation  or 
operative  procedure,  such  cases  are  not  recorded  in  this  table. 

"Extension"  of  upper  or  lower  extremity  signifies  a  displacement 
upward.  The  meaning  of  "prolapse"  is  obvious.  This  explanation  is 
given  because  the  terms  may  be  misleading,  inasmuch  as  a  prolapsed  arm 
may  be  an  extended  arm,  etc.  We  adhere  to  these  terms,  however,  in  this 
respect,  as  they  are  in  common  use.  In  the  10,233  cases  reported,  there 
were  242  early  abortions.  The  cases  here  tabulated  may,  therefore,  be 
said  to  have  occurred  in  9,991  cases  of  labor. 

Upper  extremity :  Cases. 

Prolapse 72 

Extension 23 

Lower  extremity : 

Prolapse 14 

Extension 16 

Funis — Prolapse 106 

Placenta  Prsevia 31 

Presentation  in  Cases  of  Displacement  of  Foetal  Parts. 

In  the  cases  of  prolapse  of  the  upper  extremity,  the  presentation  was 

as  follows : 

Cases. 
Yertex  presentation 35 

Breech           "           1 

Shoulder        "           36 

Total 72 

Tw4ns,  8  cases. 

In  the  cases  of  extension  of  the  upper  extremity,  the  presentation  was 
as  follows: 

Cases. 
Yertex  presentation 1 

Breech           "            21 

Shoulder        "            1 

Total 23 

Twins,  2  cases. 

In  the  cases  of  prolapse  of  the  lower  extremity,  the  presentation  was 

as  follows: 

Cases. 
Yertex  presentation 1 

Breech  ''  10 

Shoulder        "  3 

Total 14 


82  REPORT   OF  THE  SOCIETY   OF  THE   LYING-IN   HOSPITAL. 

In  the  cases  of  extension  of  the  lower  extremity,  the  presentation  was 
as  follows: 

Cases. 

Breech  presentation 11 

Shoulder  ' '  5 

Total 16 

Twins,  1  case. 

In  the  cases  of  prolapse  of  the  funis,  the  presentation  was  as  follows: 

Cases. 

Vertex  presentation 61 

Breech  "  20 

Shoulder        "  24 

Face  ''  1 

Total 106 

Twins,  10  cases. 

Sex  of  Child. 

In  the  10,233  cases,  the  sex  was  observed  in  9,661  cases. 

Cases. 

Male 5,088 

Female 4,573 

Total 9,661 

Delivery  of  Placenta. 

9,034  observations.  Cases. 

Natural  forces 1,517 

Expression 7,335 

Manual  extraction 182 

Total 9,034 

Implantation  of  Cord. 

9,305  observations.  Cases. 

Central 5,232 

Lateral 3,622 

Marginal 447 

Velamentous 4 

Total 9,305 


Cases. 

Normal 8,127 

Calcareous 749 

Succenturiata 24 

Apoj»lectic 30 


Condition  of  Placenta. 

9,670  observations. 

Cases. 

Cystic 30 

Fibrous 290 

Fatty 420 

Total 9,670 


STATISTICAL   SYNOPSIS. 


83 


Tempeeatuee  of  Mother  (one  houe  aftee  laboe). 
8,948  observations. 

Cases. 


95i°-  96i°  15 

90^°-  9Yi° 109 

97i°-  98i°  3,027 

9Sr-  99r  4,905 


99i°-100*° 


783 


100i°-101i° 
101i°-102i° 
102i"-103i° 
103i°-lo4° 


Cases. 
90 
14 


Total 8,948 


Pulse  of  Mother  (one  hour  after  labor). 
9,107  observations. 
Cases. 


30-40 2 

40-50 25 

50-60 415 

60-70 1,824 

70-80 3,874 

80-90 2,118 


90-100 
100-110 
110-120 
120-130 
130-140 


Cases. 
599 
141 

84 

18 

7 


Total 9,107 


Vaginal  Examinations. 
First  Stage. 


Cases. 

327 

6 

1,222 

7 

1,071 

8 

1,199 

9 

714 

10 

10  and  over. 


These  examinations  were  made  by : 

Cases. 
Pupils  of  the  Hospital 5,109 


House  Staff. 


Midwives 9 

Second  Stage. 


Cases. 

1 1,269 

2 2,098 

3 1,224 

4 972 

6 467  , 

These  examinations  were  made  by 

Cases. 
Pupils  of  the  Hospital 5,843 


6 

7 

8 

9 

10  and  over, 


House  Staff. 


Cases. 
654 
359 
261 
122 
396 


Cases. 

1,907 


Cases. 
438 
179 
162 
80 
137 


Cases. 
1,912 


Midwives 19 


84 


REPORT   OF   THE  SOCIETY   OF   THE   LYIXG-IN  HOSPITAL. 


Wekuit  of  Child  at  JBiktii 
9,389  observations. 
Cases 


1-2 

lbs 

2-8 

•« 

3-4 

(( 

4-5 

'' 

5-0 

'' 

6-7 

7-8 

u 

8-9 

(( 

9 

22 

81 

153 

452 

1,355 

3,440 

2,314 


Cases. 
9-10  ll)s 1,052 


10-11 
11-12 
12-13 
13-14 
14-15 


340 
128 

27 
7 
3 


Total 9,389 


Tempeeatuke  of  Child  at  Birth. 
0,90o  observations. 
Cases. 


96*'-  97°  777 

97°-  98° 1,590 

98°-  99° 2,703 


99°-100= 


1,538 


100°-101° 
lOl°_102° 


Cases. 

312 

34 


Total 0,900 


Temperature  of  Mother  during  the   Puerperium. 

A.M. 


96^° 

974° 

98^ 

99i° 

100^° 

1014° 

102i° 

103i° 

1044° 

ISTuinber 

Day. 

to 

to 

to 

to 

to 

to 

to 

to 

to 

of  Cases 

97r 

98^° 

99i° 

100i° 

101i° 

102i° 

103^° 

104i° 

1054" 

Observed. 

Labor. 

37 

871 

1,740 

291 

20 

0 

2 

3 

2,970 

1st . . . 

106 

3,867 

4,148 

394 

57 

34 

11 

5 

8,022 

2d  ... 

106 

3,709 

4,244 

387 

04 

33 

10 

(i 

1 

8,500) 

3d  ... 

70 

3,493 

4,292 

482 

97 

38 

20 

10 

8 

8,510 

4th... 

62 

3,204 

4,070 

472 

77 

50 

22 

13 

7() 

8,112 

5th... 

69 

3,338 

3,908 

431 

88 

35 

22 

4 

7,955 

6th... 

57 

3,045 

3,018 

302 

90 

43 

24 

5 

7,250 

7th... 

50 

2,605 

2,958 

337 

53 

38 

24 

() 

0),()71 

8th... 

37 

2,300 

2,453 

249 

30 

23 

15 

0 

3 

5,128 

9th... 

46 

1,531 

1,503 

133 

28 

19 

14 

0 

3 

3,343 

P.M. 


I.,abor. 

44 

1,136 

2,516 

683 

83 

19 

2 

4,483 

1st . . . 

86 

2,937 

3,726 

476 

84 

28 

19 

4 

3 

7,303 

2d  ... 

54 

2,186 

3,088 

486 

101 

42 

10 

4 

1 

5,978 

3d  ... 

1  44 

1,715 

2,537 

544 

87 

51 

31 

12 

1 

5,022 

4th .  . . 

29 

1,277 

2,033 

358 

102 

50 

25 

6 

1 

3,881 

5th . . . 

24 

1,158 

1,841 

305 

70 

41 

26 

10 

4 

3,47!> 

6th .  . . 

19 

709 

930 

183 

57 

31 

22 

8 

5 

1,904 

7th... 

16 

553 

629 

146 

48 

22 

15 

12 

3 

1,444 

8th... 

19 

398 

509 

90 

31 

28 

18 

8 

4 

1,105 

9th... 

3 

236 

318 

70 

23 

13 

13 

7 

2 

085 

STATISTICAL   SYNOPSIS. 


85 


Pulse  of  Mother  during  the  Pueeperium. 


A.M. 


50 

60 

70 

80 

90 

100 

110 

120 

130 

JSTumber 

Dav. 

to 

to 

to 

to 

to 

to 

to 

to 

to 

of  Cases 

60 

TO 

80 

90 

100 

110 

120 

130 

140 

Observed. 

Labor 

.  150 

604 

1,322 

642 

523 

134 

46 

8 

1 

3,430 

1st  .  . 

399 

1,785 

4,048 

1,767 

501 

114 

48 

16 

6 

8,684 

2d  .. 

256 

1,419 

4,100 

2,029 

559 

157 

49 

14 

6 

8,589 

3d  .. 

166 

1,232 

4,075 

2,218 

677 

153 

60 

1 

1 

8,583 

4th.  . 

185 

1,230 

3,965 

1,932 

609 

121 

68 

9 

3 

8,122 

6th.  . 

209 

1,271 

3,953 

1,775 

517 

139 

42 

9 

3 

7,918 

6th.. 

240 

1,243 

3,692 

1,536 

418 

91 

32 

11 

2 

7,265 

7th.. 

140 

859 

3,017 

1,370 

433 

100 

45 

8 

3 

5,975 

8th.. 

132 

803 

2,617 

1,116 

314 

95 

28 

9 

2 

5,116 

9th.. 

91 

498 

2,072 

777 

183 

55 

14 

6 

3.696 

P.M. 


Labor 

.  257 

924 

1,856 

970 

284 

75 

34 

7 

4 

4,411 

1st.  . 

316 

1,365 

3,314 

1,681 

416 

115 

30 

17 

10 

7,264 

2d  .. 

164 

909 

2,658 

1,563 

473 

139 

66 

19 

3 

5,994 

3d  .. 

128 

676 

2,184 

1,398 

424 

129 

69 

18 

5 

5,031 

4th.. 

91 

592 

1,683 

1,044 

317 

98 

53 

16 

14 

3,908 

5th.  . 

91 

572 

1,625 

828 

223 

69 

38 

12 

7 

3,465 

6th.. 

69 

340 

878 

437 

150 

47 

35 

14 

32 

2,002 

7th.. 

26 

184 

608 

326 

121 

51 

22 

7 

2 

1,347 

8th.. 

22 

118 

474 

275 

110 

62 

15 

5 

2 

1,083 

9th.. 

21 

90 

296 

156 

75 

23 

8 

1 

3 

673 

An  Analysis  of  Cases  of  Vertex  Presentation. 

Total  number  of  cases  of  vertex  presentation 8,495 

l!^umber  of  mothers  who  sm^vived 8,466 

"    died- 29 

N^mnber  of  children  born  alive 8,284 

still-born 211 

"                 "         dying  during  puerperium 149 


*  Among  the  29  cases  are  four  cases  of  women  with  twin  children,  one  of  which 
was  a  breech  presentation.  These  four  women,  therefore,  appear  again  as  mothers 
who  died,  in  the  corresponding  entry  under  Analysis  of  Breech  Presentatioii. 

Moreover,  there  are  four  cases  of  death  of  mothers  which  were  confined  by  mid- 
Avives,  the  presentations  of  which  are  unknown  to  the  Hospital. 


86  REPORT  OF  THE   SOCIETY  OF  THE   LYING-IN   HOSPITAL. 


Day  of  Dkatii   of  ]\Iotiikrs. 

5  mothers  died  on Labor  day 

7         *'  "         1st  day  postpartum. 

4         "  -  2d      ''" 

L>         -  ••  4th     " 

3         "  '*  (Uh    " 

2         "  "         Tth     "  " 

1  mother  ''         10th  "  " 

1         "  ''  11th  "  '* 

I         .»  - 02d    "  " 

1  "  "  25th  "  " 

1         "  "         an  unknown  day  in  I)elle\'ue  Hospital. 

1         "  ''         an  unknown  day  after  the  2Tth  day  post- 

partum in  Bellevue  Hospital. 

29 


Cause  of  Death  of  JVIoTnERs  in  Cases  of  Vertex  Presentation. 

(See  list  of  Fatal  Cases,  C.  X.  101;  420;  1,016;  1,198;  1,425;  1,547; 
1,723;  2,381:  2,429;  3,267;  3,314;  3,351;  3,564;  4,655,  twins;  4,683; 
4,726;  5,190;  5,473;  5,633;  5,708;  5,799;  6,235;  6,925;  7,070;  7,263; 
7,538;  8,034;  10,047;  10,218,  twins.) 

Cases. 

Acute  Nephritis;  a?deraa  of  the  lungs 1 

Consultation  case;  antepartum  haemorrhage;    woman  moribund  upon 

arrival  of  Hospital 1 

Erysij)elas,  facial 1 

Inanition ;  no  cause  could  be  assigned,  except  the  low  physical  condition 

of  the  woman  l)efore  labor 1 

]\forbus  ]\Iaciilosus  WcM'lliofii;  ])ostpartum  htemorrhage 1 

Pneumonia,  acute  ]ol);ir 1 

Placenta  pi-evia 1 

J'hthisis;  luLTiiorrhage  Jiiid  (edeiiiii  of  lungs. 1 

Postpai'tiiiii  liji'iiiorrhage  in  induction  of  l;il)oi',  Ttli  moiilli 1 

Kuj)ture  oi  ut<!rus  (one  case  with  septica-iiiia  ;ilso) 3 

iScj)tica'iiii;i  (one  e;is(!  witli  pliieejitii  ])ra'viii  ;in(l  one  ;i  midwife  case),  ...  8 
Surgical  kidney  in  ndh-xue   ilos|)ital  al'tei-  opeiation  I'oi-  vesico-vaginal 

fistula  ac(juii"ed  undei-  eai-c  of  outside  ])hysicians 1 

Uritniid  and  eclampsia 8 

Total 29 


statistical  synopsis.  87 

Possible  Causes  of  Still  Birth  in  Cases  of  Yeetex  Presentation, 

Cases. 

Anencephalus 1 

Child  of  unusual  size  (15  lbs.),  difficulty  in  delivery  of  head 1 

Cord  around  child's  neck  once 7 

"         "           "          "     three  times ,    1 

''         "           "          "     five  times,  once  around  shoulders 1 

"         "           "        shoulders 2 

Deformed  pelvis  in  mother 8 

' '     cord  around  neck  once 1 

' '     prolapse  of  cord 5 

"     tonic  contraction  of  uterus,  prolonged  labor — 93  hours.  1 

"     fracture  of  child's  skull 2 

' '     prolapse  of  cord ;  hydramnios 1 

' '     prolapse  of  cord  and  upper  extremity 1 

' '     hydrocephalus 1 

' '     cord  around  neck ;  pressure  of  forceps  blade  upon  cord .  1 

Extreme  moulding  of  child's  head 1 

Eclampsia , 1 

Eclampsia ;  twins 2 

Hydramnios 2 

Hydrocephalus 1 

' '              prematurity 1 

Macerated  34 

' '           prematurity 9 

"           hydrocephalus 1 

"           twins 2 

' '          deformed  pelvis 1 

Prematurity 11 

"           tAvins 1 

' '           cord  around  neck  of  child  once 2 

Prolapse  of  cord 11 

"            "       twins 1 

"            "        extension  of  upper  extremity  after  version 2 

"            "       and  of  upper  extremity ;  fracture  of  humerus 1 

Prolonged  labor 4 

"             "     cord  around  neck  of  child  once 1 

Placenta  praevia 2 

"             "       prematurit}^ 1 

"             "       prolapse  of  upper  extremity 2 

Eupture  of  uterus 4 

"               "      prolapse  of  cord 1 

Twins 9 

Tonic  contraction  of  uterus ;  contraction  ring ;  patient  in  state  of  col- 
lapse ;  delivery  attempted  by  outside  physicians 1 

]S"o  complications 68 

Total 211 


88  REPORT  OF  THE   SOCIETY   OF  THE   LYING-IN   HOSPITAL. 

Day  of  Dkatii  of  Children  in  Vertex  Presentation,  Dying  During 

the  puerperium. 

Of   the   8,284   children   born  aliYe  in  Yertex    presentation,   149  died 
during  the  puerperiunu 

85  children  died  on  the 1st  day  of  life. 

14         "  ''       "       2d      "        " 

8  "  "       *'       3d      "        " 

9  ''  ''       "       4th    "        " 

6         "  "       "       5th    "        " 

5  "  "  "  Cth    " 

6  "  "  "  7th    ^'  " 

3         "  "  "  Sth    "  " 

3         "  "  ''  0th    "  " 

3        "  "  "  loth"  " 

1  child  "  "  13th" 

•2  children  ''  "  loth" 

1  child  •'  "  18th" 

1      "  "  "  19th"        " 

1      "  "  "  21st  "        " 

1      "  "  "  23d   "        " 

149 

The  remaining  8,135  children  were  discharged  from  the  care  of  the 
Hospital  in  good  condition. 

Causes  of  Death  of  Children  in  Cases  of  Vertex  Presentation,  Dying 

During  the  Puerperium. 

Cases. 

Anencejihalus 1 

Atelectasis 9 

As]>hYxia 1 

Convulsions 3 

' '           forceps 2 

"           eclampsia  in  mother 1 

"  fontanelles  bulging;  pressure  <tii  fontaiiollcs  ])roduced  con- 

vulsi(jiis 1 

Cholera  infantum 1 

Deformed  jiel vis ;  forceps 1 

T)<'])rr'ss('(l  friictiii'c  of  sl<iill:  (Icfoj-mcd  |»('lvis;  version 1 

Ervsipf'las 2 

Eclampsia  in  mother;  accouchement  force 1 

Fo'tal  deformities;   un<h'velo]X'd 0 

Found  dead  upon  postpartum  visit;  ncv(,'i'  ))resente(l  any  symptoms.  ...  3 

Haemorrhage  from  cord;  jiarents  attem])ted  to  detach  cord  forcibly. ...  1 

IIa*mophilia 4 


STATISTICAL   SYNOPSIS.  89 

Inanition ;  could  not  be  fed 2 

Opium;  overdose  given  by  parents 1 

Pneumonia 8 

Prematurity  (before  the  eighth  month) 36 

' '  fatty  placenta 1 

' '  deformed  pelvis 1 

Spina  bifida 1 

Syphilis 3 

Suppurative  infection  of  umbilical  cord 1 

"  "  "  "    icterus 1 

"  "  "  "    cerebro-spinal  meningitis 1 

Suspended  animation 22 

"  "         placenta  prsevia ;  version ....     2 

"  "         forceps 1 

"  "         hydramnios 1 

Weak  and  poorly  nourished  at  birth 10 

No  cause  assigned 16 

"       "  "       cyanosis 3 

149 
With  regard  to  the  above  table,  and  similar  tables  under  other  presenta- 
tions, it  should  be  said  that  it  is  often  difficult  for  the  Hospital  to  arrive 
at  any  satisfactory  opinion  as  to  cause  of  death,  both  on  account  of  the 
difficulty  of  obtaining  autopsies  and  because  the  children  are  so  little 
under  observation  in  the  outdoor  service.  We  have,  therefore,  recorded 
every  symptom  and  circumstance  which  could  throw  light  on  the  cause  of 
death.  There  are  many  cases  of  prematurity,  and  many  cases  in  which 
the  children  are  of  very  low  weight,  poorly  nourished,  of  low  vitality,  and 
it  is  practically  impossible  to  feed  them  under  tenement-house  conditions. 
Such  children  are  included  under  the  headings,  Prematurity,  Inanition, 
Suspended  Animation,  Weak.  It  has  also  happened  that  children  who 
were  perfectly  well  at  the  last  visit  of  the  Hospital,  have  been  found  dead 
upon  a  subsequent  visit. 

An  Analysis  of  Cases  of  Breech  Presentation. 

Total  number  of  cases  of  breech  presentation 341 

Number  of  mothers  who  survived 335 

"     died-^ 6 

Number  of  children  born  alive 255 

"                 "         still-born 86 

"                 "         dying  during  puerperium 35 

Day  of  Death  of  Mothers. 

1  mother  died  on Labor  day. 

1       "  "    " 1st  day  postpartum. 

Smothers    "    " 2d      "  " 

1  mother      "     " 22d     "  " 

*  Of  these  six  cases,  there  are  four  cases  of  twins,  in  which  one  child  was  a  vertex 
presentation.     (See  footnote  under  Analysis  of  Vertex  Presentation.) 


90  report  of  the  society  of  the  lyixg-ix  hospital. 

Cause  of  Death  of  Mothers  in  Cases  of  Breech  Presentation. 

(See  list  of  Fatal  Cases,  C.  K  SG4;  1,547;  2,881;  4,655;  5,955;  10,218.) 

Cases. 

Erysipelas 1 

SepticaMuia 1 

Suppression  of  urine ;  Ca?sarean  section 1 

Uraemia  and  eclampsia 3 

6 

Possible  Causes  of  Still  ])Irth  in  Cases  of  Breech  Presentation. 

Cases. 

Anencephalus 2 

Cord  around  neck  of  child  three  times 1 

Deformed  pelvis 3 

Early  ru])ture  of  membranes  (several  days) :  tonic  contraction  oi  uterus  1 

Ilydrocej)halus 3 

Lower  extremity  extended;  in  labor  three  days  before  calling-  Hospital.  1 

Macerated 11 

deformed  pelvis ... 2 

"         prematurity 12 

'*         cord  around  neck  of  child  six  times 1 

uj)per  extremities  extended 1 

'*'        both  upper  and  lower  extremities  extended 1 

Prematurity 5 

hydramnios 1 

'*           cord  around  neck  of  child  once   1 

••           twins 2 

Prolapse  of  cord 1 

• '              ' '     upper  extremities  extended 1 

"              "         "             "                 "          fracture  of  Immerus 1 

"              '•         '^             "                 "                 ''             jaw 1 

"              "     pi'fjlapse  of  lower  extremities;  u])p(n'  extremities  ex- 
tended    1 

Upper  extremities  extended 1 

''         ])r(>lapse  of  lower  extremities;  contraction 

ring  present 1 

"             "                 "         tofTother  with  lower  extremities 1 

*'  "  "         togetlier     witli     lower    extremities;     arms 

locked  Itcliiiid  head 1 

"              *'                  "         twins 1 

Midwife  in  charge  of  case;  delay  of  oim-  lioiir  in  l)ii'tli  of  shoulders.  ...  I 

Neglected  breech;  cliiM  partly  born  upon  anivai  of  Hospital 1 

Placenta  praivia;  juiMiiaturity 1 

Twins 3 

No  comi)licatioiis 22 

80 


STATISTICAL   SYNOPSIS.  91 

Day  of  Death  of  Children  in  Cases  of  Breech   Presentation,  Dying 

During  the  Puerperium. 

Of  the  255  cliildreii  born  alive  in  breech  presentation,  35  died  during 
the  puerperium. 

23  children  died  on  the 1st  day  of  life. 

4         "  "  ''  3d      "  " 

1  child  "  ''  4th    " 

1     ''  ''  " Tth    "  " 

1     "  "  "  9th    "  " 

1     "  "  "  nth  "  " 

1     "  '<  "  12th  "  " 

35 

The  remaining  220  children  were  discharged  from  the  care  of  the  Hos- 
pital in  good  condition. 

Causes  of  Death  of  Children  in  Cases  of  Breech  Presentation, 
Dying  During  the  Puerperium. 

Cases. 

Atelectasis 2 

' '         prematurity 1 

Anencephalus 1 

' '            Csesarean  section 1 

Cholera  infantum 2 

Convulsions ;  icterus ;  umbilical  stump  normal 1 

Foetal  deformities ;  undeveloped 1 

Delayed  labor;  head  caught  in  cervix 1 

Prematurit}^ 11 

' '           fatty  placenta 1 

Pneumonia 2 

Suspended  animation 4 

Spina  bifida 1 

S3q3hilis 1 

Small  hgemorrhage  into  pleura  and  pericardium;  no  cause  discovered 

on  autopsy 1 

Weak 2 

No  cause 2 


An  Analysis  of  Cases  of  Shoulder  Presentation. 

Total  nmnber  of  cases  of  shoulder  presentation 91 

Number  of  mothers  who  survived 84 

"     died 7 

"            children  born  alive 67 

"                   "        still-born 24 

"                   "        dyiiig  during  the  puerperium 2 


35 


92  report  of  the  society  of  tpie  lying-in  hospital. 

Day  of  Death  of  Mothers. 

3  mothers  died  on Labor  day. 

1  mother  died  on 1st  day  postpartum. 

1         '^        "         8d      •■'  " 

1         "        "         10th  "  " 

1         ''        "  I'ith  "  " 


Cause  of  Death  of  Mothers  in  Cases  of  Shoulder  Presentation. 

(See  list  of  Fatal  Cases,   C.    N.    330;    349;    426;    769;  3,562;    5,686; 
5,824.) 

Cases. 

Carcinoma  of  the  cervix ;  j^ostpartum  haemorrhage 1 

Pneumonia,  acute  lol>ar 1 

Placenta  pra-via 2 

Prolonged  labor;  imjmcted  shoulder;  midwife 1 

Septicaemia;  pneumonia 1 

Uraemia  and  eclampsia 1 


Possible  Causes  of  Still  Birth  in  Cases  of  Shoulder  Presentation. 

Cases. 

Anencephalus :  liydramnios 1 

Deformexl  pehis 

"  ''     impaction  of  shoulder  at  outlet;  decapitation 

Forceps  to  after-coming  head 

Prematurity 

Placenta  ]>rievia 

"  "      ])rematurity ;  prolapse  of  cord 

Prolapse  of  cord 

"  "     ])rola])S('  of  n]~)p('r  oxtroniities 

"  '•  "  ••  "         tonic  contraction  of  uterus 

"  ''     and  riglit  luiiid  :   left  arm  extended 

Prolapse  of  upj^er  extremities 

"  ''  "  case  in  cliar^^c  of  midwife 

"  "  coi-(l  four  times  ai-oiiiid  neck  of  cliild.... 

UplMT  cxtremitif's  oxtfTidcd;  coi-d  oiicc  ai-omid  ii('(l<  of  child 

Ura-mia  in  motlKT 

Tonic  contraction  of  uterus;  contractifxi   lini^-  ])i('sent 

Twins 1 

Ko  coiiij)licalions 3 

24 


statistical  synopsis.  93 

Day  of  Death  of  Childken  in  Cases  of  Shoulder  Presentation, 
Dying  During  the  Puerperium. 

Of  the  67  children  born  alive,  2  died  during  the  puerperium. 

1  child  died  on  the 1st  day  of  life. 

1     "       "         "       5th    ''  " 

Causes  of  Death  of  Children  in  Cases  of  Shoulder  Presentation, 
Dying  During  the  Puerperium. 

Cases. 

Convulsions ;  no  cause 1 

Suspended  animation ;  placenta  prsevia 1 

The  remaining  65  children  were  discharged  from  the  care  of  the  Hos- 
pital in  good  condition. 

An  Analysis  of  Cases  of  Face  Presentation. 

Total  number  of  cases  of  face  presentation 36 

ISTumber  of  mothers  who  survived 36 

"                "           "     died 0 

"           children  born  alive 33 

"                 "         still-born 3 

"                 "         dying  during  the  puerperium 3 

The  position  in  the  36  cases  of  face  presentation  was  as  follows: 

Cases. 

L.  M.  A 12 

R  M.  A n 

Cases. 

L.  M.  P 7 

E.  M.  P _6 

13 

Cases. 

In  the  anterior  positions,  delivery  occurred  by  normal  mechanism 19 

Whole  child  turned  to  obtain  a  vertex  anterior  position 1 

Manual  assistance  to  flexion  as  face  was  born 1 

Podalic  version  for  prolapse  of  cord 1 

"  "       "   uterine  inertia 1 

23 

Cases. 
In  the  posterior  positions,  delivery  occurred  by  normal  mechanism  ....     3 

Manual  rectification  to  vertex  anterior  position 1 

Podalic  version 5 

Forceps  with  rotation  to  mento-anterior 4 

13 


94  refort  of  the  society  of  the  lying-in  hospital. 

Possible  Causes  of  Still  Biktii  in  Cases  of  Face  Presentation. 

Cases. 

Anencephrtlus;  hytlraimiios 1 

Attemj)ted  forceps;  poilalic  version;  woman   had  been  the  subject  of 

Alexander's  ojieration 1 

Kectitication  attempted;  }K)dalic  version 1 

~3 
Day  of  Death  ok  Children  in  Cases  of  Face  Presentation,  Dying 
During  the  Puerperiim. 
Uf  the  o."^>  chiUlrcn  born  alive  in  face  presentation,  3  died  during  the 
puerperium. 

1  child  died  on  the 1st  day  of  life. 

2  children  died  on  the .2d  day  of  life. 

The  remaining  3o  children  were  discharged  from  the  care  of  the  IIos 
pital  in  good  condition. 


&" 


Causes  of  Death   of  Children  in  Cases  of  Face  Presentation,  Dying 

During  the  Puerperium. 

Cases. 

Broncho-pneumonia 1 

Suspended  animation 1 

''  "         podalic  version;  fracture  of  humerus     1 

3 

There  were  four  cases  of  Ijrow  presentation. 

All  of  the  mothers  survived,  and  all  of  the  children  were  born  alive. 

In  two  cases  the  brow  presentation  was  changed  manually  into  an  ante- 
rior position  of  the  vertex.  In  one  of  these  two  cases,  labor  was  there- 
after terminated  normally.  In  the  other  case,  forceps  failed  to  accomplish 
tlelivery,  and  podalic  version  was  performed.  This  child  subsequently 
developed  into  a  microcephalic  idiot. 

In  one  case  the  brow  presentation  changed  spontaneously  into  an  ante- 
rior position  of  the  face,  and  labor  progressed  to  a  normal  termination. 

In  one  case  s\nnphysiotomy  was  ]:)erformed  for  deformed  pelvis.  The  child 
was  then  delivered  by  podalic  version,  and  breech  extraction  after  version. 

There  \vere  also  two  cases  in  which  the  ear  presented.  In  one  case  the 
child  was  born  alive  by  means  of  podalic  version.  In  one  case  the  lower 
uterine  segment  was  so  thinned  that  podalic  version  was  not  considered 
a  sjife  procedure.     The  child  was  dead,  and  craniotomy  was  performed. 

It  will  Ijc  noted  that  the  children  whose  day  of  death  and  the  causes  of 
wliose  death  have  been  recorded  in  the  preceding  tables  under  the  analysis 
of  the  several  ])resentations,  are  children  whose  ])resentation  was  observed 
at  the  time  of  hdx^r.  Tliere  were  also  l,li 04  eases  in  which  the  i)resen- 
tation  was  nr>t  observed.  Among  these  l,2<i4  cases  there  were  813 
eliildren  bf)rn  aliv(;.  Of  these  Hi 3  children  born  alive,  2.")  died  during 
the  piuTperinm.  In  order,  therefore,  to  make  c()m])h!te  the  records  of 
death  of  chil<lr<-ii  dying  (hii-ing  the  puerjici  iimi.  the  following  lables  must 
1»<'  add<'d : 


STATISTICAL   SYNOPSIS. 


95 


Day  of  Death  of  Children  in  Cases  in  which  Presentation  could 
NOT  BE  Observed,  Dying  during  the  Pueeperium, 
15  children  died  on  the 1st  day  of  life. 


4 

a              u 

1 

child 

1 

1 

1 

1 

1 

25 

2d 
3d 

7th 

9th 

13th 

15th 

23d 


The  remaining  788  children  born  alive  in  cases  in  which  presentation 
could  not  be  observed,  were  discharged  from  the  care  of  the  Hospital  in 
good  condition. 

Causes  of  Death  of  Children  in  Cases  in  which  Presentation  could 
NOT  BE  Observed,  Dying  during  the  Puerperium. 

Cases. 


Atelectasis;   prematurity 

' '  twins 

Foetal  deformities;  undeveloped 
Haemophilia , 


1 

1 

1 

1 

Haemorrhage  from  nose;  found  dead  upon  postpartum  visit 1 

Pneumonia 1 

Prematurity  8 

Purulent  conjunctivitis ;  tympanites ;  diarrhoea 1 

Suspended  animation 1 

Stomatitis 1 

Traumatism ;  fell  to  floor  in  precipitate  labor 1 

Unattended;  deep  cyanosis  and  cold  surface;  moribund  upon  arrival  of 

Hospital 1 

"Weak ;  could  not  be  fed , 1 

No  cause  or  symptoms  found 5 

25 
Umbilical  Cord. 

7,787  observations.  Cases. 

The  cord  was  detached  on  the 1st   day  in  3 


2d 

61 

3d 

655 

4th 

'     1,799 

5th         ' 

'      2,203 

6th 

'      1,648 

7th 

829 

8th 

413 

9th         ' 

139 

10th       ' 

37 

7,787 


96  report  of  the  society  of  the  lyixg-in"  hospital. 

Uterus. — Heiuht  ahovk  Symphysis,  in  Inches,  during  Puerperium. 


Day. 

4 

t— 1 

09 

CO 

c 

1— ( 

h- 1 

<v 
c 

1— 1 

09 

CO 

<v 

o 

a 

H-l 

o 
c 

t— 1 

CO 

o 
1—1 

CO 

a; 

o 
c 

(— 1 

cr 

o 
c 

CO 

O 
l-H 

CO 

imber 
Cases 
>served. 

l-H 

12 

CM 

CO 

TtH 

>o 

O 

755 

GO 

Oi 

o 

T— 1 

T— 1 
T— 1 

CM 

CO 

1—1 

^^O 

Labor  

IS 

109 

580 

1,729 

1,957 

165 

29 

6 

1 

1 

5,362 

1st 

24 

59 

347 

1,691 

3,411 

2,671 

797 

174 

24 

10 

9,208 

L>a 

21 

110 

748 

2,873 

3,331 

1,572 

354 

87 

10 

1 

9,113 

3a 

31 

274 

1,626 

3,564 

2,565 

777 

137 

17 

2 

1 

8,994 

4tli 

75 

522  2,559 

3,291 

1,620 

375 

62 

10 

8,520 

:.th 

144 

1,033  2,830 

2,801 

1,085 

208 

26 

4 

8,131 

«;th 

L>4«; 

1,379  2,700 

2,081 

012 

120 

15 

7,159 

Tth 

:VSu 

1,27»»  2,114 

1,232 

410 

74 

11 

.  , 

5,441 

^;th 

313 

1,1211,547 

724 

108 

49 

5 

2 

1 

1 

3,931 

y  th 

250 

539     768 

330 

91 

18 

2 

2,004 

Plural  Births. 

In  the  period  covered  by  this  report  of  10,233  cases  there  were  161 
cases  of  twins,  or  one  to  every  63.55  cases. 
There  was  one  case  of  triplets. 

Presentation. 

In  the  132  cases  of  twins  in  which  it  was  possible  to  make  observa- 
tions, the  presentation  was  as  follows: 


Cases. 

Vertex  and  breech 58 

Both  vertex 55 

Both  breech 11 

Vertex  and  face 1 


Breech  and  shoulder 
Vertex  and  shoulder 


Cases. 
4 

3 


Total 132 


In  the  case  of   triplets,  the   presentation   was,  first,   vertex;    second, 
breech;  third,  vertex. 

Placenta. 

In  the  arrangement  of  placenta  and  membranes  it  was  found  that  the 
placenta  was: 

Cases. 

Single 71 

Double 82 

Unknown  8 

Total 101 


STATISTICAL   SYNOPSIS.  97 

Amniotic  Cavity. 

The  amniotic  cavity  was: 

Cases. 

Single 7 

Double 95 

Unknown ,     59 

Total 161 

In  the  case  of  twins  there  was: 

Cases. 

A  single  placenta  and  double  amniotic  cavity 43 

A  single  placenta  and  single  amniotic  cavity 4 

A  double  placenta  and  single  amniotic  cavity 1 

In  the  case  of  triplets  there  was  a  double  placenta  with  a  very  small 
placenta  succenturiata.     There  was  a  double  and  a  single  amniotic  cavity. 

Sex. 

In  the  case  of  twins  the  sex  was  as  follows: 

Cases. 

Male  and  female QQ 

Both  female 35 

Both  male 53 

Unknown 7 

Total 161 

In  the  case  of  triplets  the  sex  was : 
First  child,  female. 
Second  child,  male. 
Third  child,  male. 

Mortality. 
The  result  to  mother  and  child  in  the  twin  cases  was  as  follows: 

Cases. 

Mother  living 156 

"      dead 5 

Total 161 

Living  children 287 

Still-born 35 

Total 322 

In  the  case  of  triplets,  all  three  children  were  living. 

Cause  of  Death  of  Mother. 

Cases. 

Erysipelas  (antepartum) 1 

Eclampsia  "  4 

Total 5 

7 


98  REPORT   OF  THE    SOCIETV    OF   THE    LYING-IN    HOSPITAL. 

Possible  Causes  of  Still  Bikth  in  Twin  Cases. 

Cases. 

Abortion 2 

Child  born  before  arrival  of  IIos])ital 4 

"           ''                  "        membranes  imi'ii])tiire(l 1 

"      "         "           "                  '*        early  separation  of  placenta 1 

"      "         "  "  "        midwife  in  attendance ;  bod}'"  born; 

head  retained  within  ]>elvis...  1 

Eclain])sia  in  mother;  accouchement  force 2 

Forceps  low 1 

Fci'tal  lieart  sounds  not  lieard;  c<n'd  not  pulsating 1 

Fibrous  degeneration  of  ])lacenta 1 

Macerated 7 

^Mummified  fo-tus  (pi  four  months  of  ftrtal  life,  with  living  fa^tus  of 

six  months  of  foetal  life) 1 

Placenta  praevia ;  manual  extraction ;  prematurity 4 

Prematurity ;  manual  extraction 3 

l*r(jla])se  of  funis ;  foetal  heart  sounds  not  heard 1 

Separation  of  placenta  before  labor;    antepartum  haemorrhage;    short 

umljilical  cord ;  three  coils  of  cord  around  child's  neck 1 

Shoulder  presentation;    prolapsed  arm;    extended  arm  locked  behind 

child's  head 1 

Xo  cause  assigned  in  history 8 

35 
Day  of  Death  of  Children  of  Twin  Cases,  Dying  during  Puerperium. 

Cases. 

Death  on  6th   day 2 

Tth    "' 1 

"         8th    "    0 

9th    "     2 

"         10th  "     _o 

Total 38 

The  remaining  249  children  were  discharged  from  the  care  of  the  Hos- 
pital in  good  condition. 

Causes  of  Dp:atu  in  Children  of  Twin  Cases,  Dying  during  Puerperium. 

Cases. 

Atelectasis;  prematurity 2 

Circulation  poor;  respiration  superficial 2 

Convulsions  on  6th  and  Tth  days;  icterus;  (li<<l  on  Tth  day;  born  in  Sth 
month    intrauterine    life;    uiid)ilical   cord  se})arated    on    4tli    day 

without  suppuration 1 

Cholera  infantum 1 

Ilajmorrhagos,  small   in   size,  into  ])lein"i  and   |)(')ica,i-(lium,  shown  by 

autopsy;  no  definite  cause  discovered 1 

Poorly  nourished;  would  not  nurse 5 

Prematurity  (born  before  eightli  month) IS 

Xo  cau.se  assigned  (one  child  described  as  de('|)]y  cyanosedj S 

38 


Cases. 

Death 

on  Labor  day .... 

15 

1st 

'' 

12 

2d 
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ii 

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a 

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a 

1 

a 

() 

STATISTICAL   SYNOPSIS, 


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100  REPORT   OF   THE   SOCIETY   OF   THE   LYING-IN   HOSPITAL. 


Tho  o]>Pi*ation  of  forceps  was  performed  290  times  in  the  service  of 
lO,:i;)o  cases,  or  once  in  3r).2l)  cases. 

Tlie  observations  are  tabulateil  as  follows: 

High  forceps  was  [)erfornieil  in  86  cases. 

Cases. 

Deatli  of  motlier 3 

••     child 3 

Still  birth 8 

To  after-coming  head 4 

Death  of  mother 2 

Still  birth 4 

Median  forceps  was  performed  in  87  cases. 

Cases. 

Death  of  mother 1 

''     ''    child 1 

Still  birth 10 

Low  forceps  Avas  performed  in  111  cases. 

Cases. 

Death  of  mother  .• 1 

"       "     child 2 

Still  birth 9 

iXot  noted 4 


Symphysiotomy. 

The  operation  of  sym]ihysiotomy  has  been  performed  six  times  in  the 
service  of  10,233  cases.  In  all  six  cases  the  incision  has  been  made  over 
the  joint,  and  the  joint  has  been  opened  from  behind  forward  and  from 
above  downward.  Gauze  drainage  has  been  used  for  twenty-four  hours  at 
least.  The  sutures  have  attempted  to  include  the  iibrous  tissue  over  the 
joint. 

In  all  six  cvuses  the  child  has  l)een  delivered  by  versi<m. 

In  all  six  cases  living  children  were  born,  and  the  mothers  recovered 
without  loss  of  function  and  without  inconvenience  after  resuming  their 
•iuties. 

CyKSAKKA.V     SKCniON. 

Ca?sarean  section  has  ijcen  pcrloriiicd  twice  in  the  service  of  10,233 
cases,  or  once  in  .5, 116.. 5  cases. 

In  one  caso  (C.  X.  .')..")()♦;  ;  Dr.  Markoe)  the  o])(;ration  was  performed 
for  d«f<iriiied  pelvis.     lUAh  mother  and  child  survived. 


STATISTICAL    SYNOPSIS.  101 

The  following  is  an  outline  of  the  other  case  (C.  N.  5,955;  Dr.  Edgar): 

Labor  obstructed  by  fibroid  tumor  of  lower  uterine  segment;  breech 
presentation;  hydramnios;  Caesarean  section;  anencephalic  child;  suppres- 
sion of  urine  in  mother;  fever  in  mother;  death  of  mother  forty-eight 
hours  postpartum. 

The  patient,  a  Russian,  married,  aged  35  years,  para  Y.,  tenth  month 
of  gestation,  was  first  seen  by  a  Hospital  officer,  April  9,  1894.  At  this 
time  the  patient  had  already  been  several  hours  in  the  first  stage  of  labor. 

No  history  of  any  miscarriages  could  be  obtained,  and  of  the  four  pre- 
vious labors  difficulty  had  been  experienced  in  the  last  one  only,  which 
occurred  in  1892. 

At  5  P.M.  on  April  9,  189-4,  when  first  visited  by  this  Hospital,  in  the 
labor  under  discussion,  weak  uterine  contractions  were  found  to  be  present, 
the  membranes  intact,  the  breech  presenting,  and  the  subjective  symptoms 
of  obstructed  labor  well  marked. 

Further  internal  examination  revealed  a  fibroid  tumor,  about  the  size  of 
a  small  foetal  head,  attached  to  the  left  wall  of  the  lower  uterine  segment, 
and  one  inch  above  the  ring  of  the  internal  os. 

The  tumor  was  of  a  hard  consistency  and  filled  in  the  upper  and  posterior 
space  of  the  left  half  of  the  true  pelvis.  A  space  of  only  two  inches  was 
left  between  the  right  wall  of  the  uterus  and  the  right  pelvic  wall. 

An  attempt  to  push  the  tumor  above  the  brim  of  the  true  pelvis  was 
unsuccessful,  even  after  the  patient  had  been  placed  under  ether. 

Laparotomy  was  at  once  decided  upon  as  offering  the  best  chances  for 
mother  and  child,  and  was  accordingly  performed.  The  usual  Sanger 
Caesarean  operation  was  done,  the  uterus  being  turned  out  of  the  abdominal 
cavity  before  the  incision  in  its  wall  was  made. 

An  anencephalic  foetus  was  delivered,  which  survived  forty  hours.  The 
mother  developed  total  suppression  of  urine,  with  fever,  and  died  forty- 
eight  hours  postpartum. 

A  fuller  account  of  the  case,  with  the  bibliography  of  the  subject  of 
obstructed  labor  due  to  uterine  fibromata,  will  appear  in  a  subsequent 
report. 

Craniotomy. 

The  operation  of  craniotomy  was  performed  three  times  in  the  service 
of  10,233  cases,  or  once  in  3,411  cases. 

C.  IST.  2,176. — III.  para;  ninth  month  of  gestation;  ear  presentation; 
woman  gave  previous  history  of  puerperal  sepsis  which  had  been  treated 
b}^  abdominal  section ;  uterus  firmly  bound  by  adhesions  so  as  to  be  curved 
laterally,  with  convexity  to  left  side ;  no  foetal  heart  heard ;  internal  ver- 
sion impossible,  on  account  of  inability  to  reach  feet,  due  to  mal-position 
of  uterus;  craniotomy  and  extraction;  recover}^. 

C.  N.  2,769. — Y.  para;  ninth,  month  of  gestation;  vertex;  L.  O.  A.; 
deformed  pelvis.  Podalic  version;  manual  traction  and  traction  with  ceph- 
alotribe  insufficient  to  accomplish  delivery ;  after-coming  head  perforated 
through  neck,  and  head  extracted ;  recovery. 


102  REPORT   OF   THK   SOCIETY   OF   THE    LVIXG-IX   HOSPITAL. 

C.  X.  5,411'.. — IV.  piira:  ninth  niontli  of  o-estation;  vertex;  E.  O.  P.; 
deformed  pelvis;  version  attempted;  pulseless  cord  prolapsed;  craniotomy 
and  extraction ;  recovery. 

Fatal  Cases.* 

It  should  he  said,  in  regard  to  the  following  notes  upon  Fatal  Cases, 
that  it  is  verv  rarelv  possihle  to  ohtain  an  autopsy  in  the  service  of  this 
Hospital,  <»n  acvount  of  the  religious  scruples  of  the  Hebrews. 

1.  ('.  N.  l<il. — Age  28;  III.  para;  eighth  month  of  gestation;  confined 
by  Hospital;  vertex;  R.  O.  A.;  ])ostpartum  liaMuorrhage;  septicaemia; 
pneumonia;  death  eleventh  day. 

2.  C.  K.  295. — Age  28;  II.  ])ara;  ninth  inoiitli  of  gestation;  confined 
by  midwife  ;  first  seen  sixth  day  postpartum  ;  se])ticaMnia  ;  pneumonia  ; 
metastatic  abscesses;  ha?matemesis ;  death  forty-eighth  day  postpartum. 

3.  C.  N.  330. — Age  33;  VIII.  para;  confined  by  Hospital;  shoulder 
jiresentation ;  podalic  version;  su])pression  of  urine;  ura?mia;  death  first 
day  postpartum. 

4.  C.  N.  349. — Age  34;  thirty-fourth  week  of  gestation;  confined  by 
Hospital;  shoulder  presentation ;  placenta  ])raevia;  podalic  version;  oedema 
of  lungs;  death  third  day  jiostpartum. 

5.  C.  X.  399. — Age  28;  I.  para;  confined  by  midwife;  first  seen  third 
day  j)Ost)xirtum;  se])ticfemia ;  collapse;  death  fourth  day  post])artum. 

G.  C.  X.  420. — Age  24;  I.  ])ara;  confined  by  Hospital;  hydrocephalus; 
vertex  presentation;  podalic  version;  severe  lacerations  of  cervix  and 
perineum;  septicEemia;  death  sixtli  day  postpartum. 

7.  ('.  X.  420. — Age  not  noted;  I.  para;  ninth  month  of  gestation; 
confined  by  Hospital  after  re])eated  failure  by  midwives  to  deliver  ; 
shoulder  presentation;  first  seen  in  second  stage;  sliock;  podalic  version; 
collaiiso;  death  on  day  of  confinement. 

s.  C.  X'.  709. — Age  27;  V.  para;  ninth  inontli  of  gestation;  confined 
by  Hos])ita];  shoulder  presentation;  general  condition  bad;  ])odalic  ver- 
sion; forceps  to  aftei--coming  head;  extensive  carcinoma  of  the  cervix; 
antepartum  and  post])artum  haemorrhage  from  cervix;  colla])se;  death 
seven  hours  ])ostpai'tum. 

9.  C.  X.  804. — Age  40;  VI.  para;  confined  l\y  Hospital;  breech  j^res- 
entation;  labor  easy;  ]merperium  normal  until  tenth  day;  septicaiuiia; 
sent  to  Bellevue  Hospital  fifteenth  day  postpartum;  death  twenty-second 
(lay  |)ost])artum. 

10.  (.'.  X.  99."..  —  Age  25;  V.  i)ara;  ninth  month  of  gestation;  confined 
by  midwife;  seen  Ijy  Hospital  on  first  (hiy  postpartum,  with  fever;  septi- 
caemia ;  curettage;  acute  exacerbation  of  |)uhiioiu(iy  tul)ci'culosis.  lle- 
movcfl  on  sixth  day  to  (iouverneui"  IIosj)ital;  died  twenty-sixth  day 
|)ostpartum,  cjf  tulx-reuhisis  and  s<'])ticiemia. 

'  R«g"arding  Uie  abovo  notes  on  Fatal  Cases,  it  should  !)<■  said  tliaf  tlu'  records 
sliow  that  all  tlif  cases  were  visited  rej^'-nlarly  'h'  the  attending''  physician  or  liis 
a.SHiHtant,  wliether  he  had  In-en  the  ojxM'at/or  or  not. 


STATISTICAL    SYNOPSIS.  103 

11.  C.  N.  l,Oir>. — Age  35;  VII.  para;  ninth  month  of  gestation;  con- 
fined by  Hospital ;  vertex  presentation;  labor  normal;  septicaemia;  nephri- 
tis; death  sixth  day  postpartum. 

12.  C.  ]Sr.  1,093. — Age  35;  X.  para;  ninth  month  of  gestation;  confined 
by  midwife;  labor  easy;  first  seen  third  day  postpartmn;  septicaemia; 
albuminuria;  ])neumonia;  death  sixth  day  postpartum. 

13.  C.  X.  1,198. — Age  36;  VI.  para;  sixth  month  of  gestation;  con- 
fined by  Hospital  ;  vertex  presentation  ;  placenta  praevia  ;  dilatation  by 
Barnes's  bags;  rupture  of  uterus;  podalic  version;  death  second  day,  from 
shock. 

14.  C.  K.  1,425. — Age  34;  V.  para;  ninth  month  of  gestation;  con- 
fined by  Hospital;  vertex;  E,.  O.  A.;  pulmonary  oedema  in  second  stage 
of  labor,  and  s3'mptoms  of  acute  nephritis;  death  from  above  cause  on 
fourth  day. 

15.  C.  N.  1,547. — Age(?);  para(?);  month  of  gestation  (?);  confined  by 
Hospital;  twins;  vertex  and  breech  presentations;  breech  extraction;  facial 
erysipelas  of  eight  days'  duration;  woman  first  seen  in  second  stage  of 
labor,  and  at  that  time  Avas  in  collapse;  death  from  shock  on  second  day 
postpartum. 

16.  C.  IST.  1,723. — Age  38;  VI.  para;  seventh  month  of  gestation;  con- 
fined by  Hospital;  vertex;  L.  O.  A.;  prolapse  of  hand  ;  temperature  on 
labor  day,  101.1  degrees;  pulse,  132;  broncho-pneumonia  and  death  on 
seventh  da}". 

17.  C.  N.  2,381. — Age  24;  I.  para;  ninth  month  of  gestation;  confined 
by  Hospital;  twins;  vertex  and  breech  presentations;  low  forceps;  breech 
extraction;  eclampsia;  death  on  first  day. 

18.  C.  'N.  2,429. — Age  35;  XI.  para;  ninth  month  of  gestation;  con- 
fined by  Hospital;  vertex;  L.  O.  A. ;  still  birth;  antepartum  hemorrhage; 
slight  postpartum  haemorrhage;  temperature  on  labor  day,  100.2  degrees; 
death  from  inanition,  on  seventh  day. 

19.  C.  X.  3,267.— Age  34;  VII.  para;  ninth  month  of  gestation;  con- 
fined by  Hospital;  vertex  presentation;  previously  evidently  in  charge  of 
midwife ;  patient  suffering  from  shock  when  first  seen ;  rupture  of  uterus, 
of  several  hours'  duration;  manual  extraction  of  child  and  placenta  from 
abdominal  cavity  through  utero- vaginal  rent;  death  in  thirty-six  hours, 
from  shock. 

20.  C.  ]N^.  3,314. — Age  23;  II.  para;  eighth  month  of  gestation;  con- 
fined by  Hospital  ;  vertex;  R.  O.  P.  ;  pendulous  abdomen  ;  rupture  of 
uterus;  prolapse  of  funis;  podalic  version;  manual  extraction  of  placenta; 
death  fourth  day,  from  shock. 

21.  C.  N.  3,351. — Age  22;  I.  para;  ninth  month  of  gestation;  confined 
by  Hospital;  vertex;  R.  O.  P.;  advanced  pulmonary  tuberculosis;  pul- 
monary haemorrhage  before  and  during  delivery  ;  extensive  oedema  of 
lower  extremities ;  pulmonary  oedema ;  death  from  exhaustion  in  two  hours 
postpartmn. 

22.  C.  N.  3,562. — Age  30;  VII.  para;  ninth  month  of  gestation ;  con- 
fined by  Hospital;  shoulder  presentation;  placenta  prasvia;  haemorrhage; 


104  REFORT   OF   THE   SOCIETV    OF   THE    LYING-IN    HOSPITAL. 

shock;  accouchement  force;  podalic  version ;  extraction;  death  from  shock, 
a  few  houi-s  hiter. 

-2'A.  C.  X.  :>,r)»'.4. — A«:e  lM  :  I.  i)ara;  ninth  month  of  gestation;  confined 
hv  Hospital;  vertex;  K.  O.  P.;  eckimpsia;  k)\v  forceps;  coma;  death  few 
hours  postpartum. 

•J4.  ('.  X.  4, (').">,"). — Age  22;  I.  para;  ninth  month  of  gestation;  con- 
tined  hy  Hospital  ;  twins  ;  vertex  and  hieech  presentations  ;  forceps  ; 
eclampsia;  death  on  second  day. 

2.").  C.  X".  4,«is;>. — Age  24;  II.  ])ara  ;  thirty -fourth  week  of  gestation; 
confined  liy  Hospital;  vertex;  L.  O.  A.;  eclampsia;  manual  dilatation; 
high  forceps;  death  six  hours  later. 

26.  C.  X.  4,720. — Age  22;  III.  ])ara;  ninth  month  of  gestation;  con- 
fined by  IIos])ital;  vertex;  L.  O.  A.;  Morbus  Maculosus  Werlhofii;  severe 
haemorrhage  from  mouth  and  uterus  before  and  during  labor;  general  con- 
dition bad;  forceps;  postpartum  haemorrhage.  Death  on  first  day,  from 
luemorrhage  and  shock. 

27.  ('.  X.  5,190. — Age  36;  YI.  para;  ninth  month  of  gestation;  con- 
fined by  Hospital;  vertex;  L.  O.  A.;  septiciemia  on  third  day  post]xirtum; 
transferred  to  Bellevue  Hospital  on  nineteenth  day  postj)artum  ;  subse- 
quently died  in  Bellevue  Hospital  on  an  unknown  day. 

28.  C,  X.  5,473. — Age  38;  XII.  para;  seventh  month  of  gestation; 
confined  by  Hospital;  vertex;  L.  O.  A.;  induction  of  labor  for  death  of 
cliild  in  utero  in  last  four  pregnancies;  manual  dilatation;  podalic  version; 
post])artum  luemorrhage  six  hours  after  labor;  death  from  haemorrhage  on 
first  day. 

29.  C.  X".  5,633. — Age  19;  I.  ])ara;  niiitli  month  of  gestation;  con- 
fined by  Hospital;  vertex;  L.  O.  A.;  albuminuria;  forceps  for  contracted 
pelvis;  death  on  first  day  postpartum,  of  unemia. 

30.  C.  X.  5,686. — Age  26  ;  VIII.  para  ;  ninth  month  of  gestation  ; 
confined  by  Hospital;  slioulder  ])resentation  and  prolapsed  hand;  podalic 
version;  septicicmia;  curettage;  pneumonia;  death  on  twelfth  day. 

31.  C.  X.  5,708. — Age  34  ;  IX.  para  ;  ninth  month  of  gestation  ; 
confined  by  Hospital;  vertex;  L,  O.  A. ;  high  forceps  for  contracted  ])elvis; 
sent  to  Ik'Uevue  Hos])ital  on  twenty-seventh  day  postpartmn  with  vesico- 
vaginal fistula;  subsecpiently  died  in  Bellevue  Hospital,  of  surgical  kidney. 

32.  C.  X'^.  5,799. — Age  24;  III.  })ara;  ninth  month  of  gestation;  confined 
by  Hospital;  vertex;  L.  O.  A.;  general  condition  bad;  history  of  tuber- 
culosis, rlMMunatism,  ami  cardiac  disease;  uterine  inertia;  manual  dilata- 
tion; j)odalic  version;  septicaMiiin ;  dcjith  on  twenty-fifth  day  ])ostpartum. 

33.  C  X.  5,824. — Age  35;  III.  |)ara;  nintli  month  of  gestation;  con- 
fined by  Hospital;  shoulder  presentation;  version;  (Usath  from  acute  lol)ar 
pneumonia  on  tenth  day. 

:54.  C,".  X.  5,955. — Age  35;  V.  ])ara;  ninth  ntonth  of  gestation ;  confined 
by  Hospital  ;  breech  presentation  ;  Ca'sarcau  section  for  uterine  fibroid  ; 
com|)let<;  suj)pression  of  urine;  death  on  second  day. 

35.  (y.  X.  6,235. — Age  30;  II.  j)ara;  ninth  month  of  gestation;  con- 
fined In*  Hospital  ;  twins  ;  both   vertex  presentation  ;  eclampsia  ;  manual 


STATISTICAL    SYNOPSIS.  105 

dilatation  ;  podalic  version    for  both  cliildren  ;  death  seventh  hour  post- 
partum. 

3G.  C.  N.  6,925. — Age  21;  II.  para;  eighth  month  of  gestation;  ver- 
tex; L.  O.  A.  Case  seen  in  consultation  with  outside  physician;  patient 
found  in  collapse  ;  moril)und;  symptoms  of  haemorrhage;  placenta  delivered 
by  Hospital;  death  on  first  day  postpartum. 

37.  C.  IN".  7,070. — Age  26;  II.  para;  ninth  month  of  gestation;  con- 
fined by  Hospital  ;  vertex;  L.  O.  A.  ;  eclampsia  ;  accouchement  force  ; 
Diirhssen's  incision  of  cervix;  podalic  version;  death  thirty-six  hours  post- 
partum, from  uraemia. 

38.  C.  ]Sr.  7,263. — Age  41;  XV.  para;  tenth  month  of  gestation;  con- 
fined by  Hospital;  vertex;  R.  O.  A. ;  tedious  labor;  prolapsed  cord;  rupture 
of  uterus;  podalic  version;  septiceemia;  death  on  sixth  day. 

39.  C.  ]^.  7,538. — Age  35;  Y.  para;  ninth  month  of  gestation;  con- 
fined by  Hospital;  vertex;  R.  O.  A.;  septicgemia;  death  tenth  day  post- 
partum. 

40.  C.  ]Sr.  8,034. — Age  39  ;  XIII.  para;  tenth  month  of  gestation; 
confined  by  Hospital ;  vertex  presentation ;  placenta  previa ;  manual  dila- 
tation ;  podalic  version ;  postpartum  haemorrhage ;  death  on  second  day,  of 
septicaemia. 

41.  C.  IST.  10,047. — Age  30;  XI.  para;  ninth  month  of  gestation ;  mid- 
wife found  in  attendance;  vertex;  L.  O.  A.;  deformed  pelvis;  septicaemia 
on  eighth  day;  sent  to  BeUevue  Hospital,  where  she  died  on  twenty-second 
day  postpartum. 

42.  C.  'N.  10,218. — Age  35;  lY.  para;  tenth  month  of  gestation;  con- 
fined by  Hospital;  twins;  vertex  and  breech  presentations;  eclampsia; 
death  twenty-four  hours  after  delivery,  from  uraemia. 

In  addition  to  the  above  deaths,  one  patient  died  before  delivery, 

A.  N.   8,308. — Age  26;  I.  para;  seventh  month  of  gestation;  advanced 

heart  disease;  treated  for  nine  days  with  marked  improvement;  subsequent 

heart  failure  and  death  on  the  tenth  day. 


STUDENTS   OF   THE   HOSPITAL. 


Total  number  of  graduate  students 210 

"  ''  undergraduate  students 1,335 

"  "  cases  at  which  students  assisted  in  the 

confinement 7,495 

"  "  cases  in  which  the  confinement   was 

witnessed  by  students 8,2-12 

"  "  pregnant  women  examined  by  students  5,145 


The   210   graduate    students    registered   from   the   foUowing    Medical 


Schools  : 

Medical  Department  of  the  Univei'sity 

of  the  City  of  New  York 60 

Bellevue  Hospital  Medical  College.  .  .  32 

College  of  Physicians  and  Surgeons  .  28 
Medical  and  Surgical  College  of  New 

York 1 

Memphis  Hospital  Medical  College  . .  1 

University  of  Vermont 8 

Jeffei-son  Medical  College 1 

University  of  Minnesota 2 

Dartmoutli  Medical  College 3 

Queens  College,  Kingston,  Ontario. .  1 

Bowdoin  College 1 

University  of  Virginia 4 

College  of  Phj'sicians  and  Surgeons, 

Chicago,  III 1 

Yale  Univei'sity 7 

Buffalo  University 3 

Col umhia  College,  Washington,  D.  C.  5 
New  York  Homoeopathic  Medical  Col- 
lege    2 

Chicago  Homceopathic  Medical  Col- 
lege   1 

Torontf>  Medical  College 1 

Long  Island  College;  Hospital 2 

St^.'rling  Medical  College,  Colunihus, 

Oliio 1 

I^juJHville    Medical    College,    Loui.s- 

ville,  Ky 2 

Cooler  Medical   College,  San   Fran- 
cisco    1 


Maine  Medical  College 2 

Marion  Sims  College,  St.  Louis,  Mo.       1 

St.  Louis  Medical  College 1 

Georgetown  Medical  College  2 

Woman's  Medical  College,  Chicago, 

111 2 

University  of  Montana 1 

"  "  Michigan 1 

Eclectic  Medical  College 2 

1 
1 
5 
1 
1 
3 


Chicago,  111. 
Cincinnati. . 


Atlanta        ' ' 

Syracuse      ' ' 

Albany 

Rush 

Miami  " 

Woman's     ' ' 

University  of  Jena,  Germany 1 

1 

1 

.       1 


"  "  Toronto,  Canada 

"  "  Niagara 

"  "  South  Tennessee 

College  of  Physicians  and  Surgeons, 

Baltiinoi'c 1 

KcnturUy  Scliool  of  Medicine 1 

New  York  Woman's  Infirmary 2 

Graduated  Nurse  from  the  New  York 

Hospital 1 

Graduated  Nurs(!s  from  the  German 

Hospitiil 8 

Gradiiat/'d  Nurse  from  tlu!  Womans' 
Ilos|)ital 1 

Total 210 


STUDENTS   OF   THE    HOSPITAL. 


107 


The  1,335  undergraduate  students  of  the  Hospital  registered  from  the 
following  Medical  Schools  : 


Medical  Department  of  the  Univer- 
sity of  the  City  of  New  York 582 

Bellevue  Hospital  Medical  College . .  370 

College  of  Physicians  and  Surgeons.  221 
New    York    Homoeopathic  Medical 

College  for  Women 6 

New    York  Homoeopathic    Medical 

College 49 

Long  Island  College  Hospital 17 

University  of  Virginia 1 

"            "  Kingston,  Ontario  ...  1 

Yale  University  Medical  School ....  14 

University  of  Vermont 2 

College  of  Physicians  and  Surgeons, 

Chicago,  111 1 

New  York  Eclectic  Medical  College .  5 

Albany  Medical  College 22 

Columbia   Medical   College,   Wash- 

mgton,  D.  C 5 


Harvard  University  Medical  College  1 

Womans'  Medical  College,  New  York  2 

Tufts  College,  Medford,  Mass 2 

Syi-acuse  Medical  College 2 

Dartmouth  Medical  College 14 

Jetferson  Medical  College 1 

Buffalo  University 7 

Michigan  University 2 

South  Carolina  Medical  College ....  1 

Ann  Arbor  Medical  College 1 

Niagara  University 1 

McGill  College,  Montreal,  Canada. .  1 

Toledo  Medical  College 1 

Howard    Medical   School,    Raleigh, 

N.  C 1 

Cleveland  University  Medical  Col- 
lege    2 


Total 1,335 


STATISTICAL  REPORT   OF  FORCEPS   OPERATIONS. 
By  Austin  Flint,  Jr.,  M.D. 


Of  the  various  operations  in  obstetrics,  by  far  the  most  frequently 
performed  is  a  forceps  o])eration.  The  apjilication  of  forceps  may  be  indi- 
cated in  so  great  variety  of  conditions,  that  it  has  seemed  to  the  writer 
that  the  sul)jeot  was  of  suthcient  importance  to  make  a  special  report  of  the 
cases  occurring  in  the  service  of  this  Hospital. 

All  of  the  cases  u])on  wliicli  observations  were  made  occurred  in  the 
outdoor  service  of  the  Hospital.  As  "delayed  labor"  was  the  most  fre- 
quent indication,  it  may  be  proper  to  describe  something  of  the  routine 
treatment  of  cases  in  which  forceps  were  ajiplied.  Patients  are  under  the 
immediate  care  of  students,  who  are  not  allowed,  under  any  circumstances, 
to  interfere  with  the  course  of  labor.  Reports  from  students  are  sent  to 
the  Hos])ital  at  frequent  intervals.  The  cases  are  visited  by  members  of 
the  stall"  assigned  to  outdoor  duty,  who  supervise  the  students'  work,  con- 
firm the  reports  as  regards  diagnosis,  and  instruct  the  students  in  the 
various  details  of  the  management.  In  cases  of  abnormalities  of  any  sort, 
the  details  are  sent  to  the  sub-station  or  to  tlie  Hos])ital  directly,  as  may  be 
more  convenient,  and  nothing  is  done  by  the  staff  member  present  unless 
there  is  immediate  necessity.  Cases  in  which  forceps  are  indicated  are  thus 
referred  first  to  the  Hospital,  and  from  there  to  the  attending  ])]iysician 
on  (Uity.  Tliis  routine  makes  the  application  of  forceps  less  fre(|uent  than 
is  usual  in  ]iosj)itals  conducting  a  purely  indoor  service. 

Forcej)S  were  a])|»li('d  2!>4-  times,  or  in  2.S7  ])er  cent,  of  all  cases.  This 
percentage  is  2. '.>'.»,  subtracting  the  417  abortion  cases  from  the  total. 

Tlie  general  results  were : 

Of  tlie  mothers 288  recovered. 

6  died. 

Total 294 

Of  the  chihh-eii 252  recovered. 

"  "        33  were  still-born. 

"  "        0  died  (hiring  the  puerperium. 

Total 294 


STATISTICAL   REPORT   OF    FORCEPS   OPERATIONS.  109 

This  is  a  maternal  mortality  of  2.04:  per  cent.,  and  an  infant  mortality 
of  14.35  per  cent. 

Of  the  six  fatal  cases,  five  occurred  after  a  high  operation,  and  one 
after  a  low  operation.  In  but  two  instances  could  the  fatal  result  be 
ascribed  in  any  way  to  the  operation. 

The  cause  of  death  and  operations  are  divided  as  follows: 

Cases. 

Eclampsia,  high  operation 2 

Sepsis,  "         " 2 

Haemorrhage  and  shock,  high  operation 1 

Eclampsia,  low  operation 1 

Total 6 

In  one-half  of  the  cases,  therefore,  eclampsia  Avas  the  direct  cause  of 
death,  and  the  operation  was  merely  incidental.  The  case  of  hsemorrhage 
and  shock  was  antepartum,  and  is  recorded  as  the  indication  for  the  for- 
ceps delivery.  It  is  probable  that  there  was  a  low  implantation  of  the 
placenta.  The  reraainiag  two  deaths  were  due  to  sepsis,  which  might  have 
occurred  under  the  surrounding  conditions,  even  if  the  forceps  had  not 
been  applied.  The  causes  of  the  foetal  deaths  do  not  admit  of  exact  deter- 
mination. Undoubtedly  many  of  the  still-born  children  were  dead  at  the 
time  of  operation.  ISTo  foetal  heart  sound  could  be  heard  in  a  larger 
number  of  cases  than  the  total  number  of  still-births  registered.  The 
necessity  of  making  some  exact  distinction  between  the  high,  median, 
and  low  operations,  was  appreciated  early  in  the  history  of  the  Hospital,  but 
it  was  not  until  a  large  number  of  operations  had  been  recorded  that  such 
a  distinction  was  made.  The  figures  in  the  whole  series,  therefore,  make 
no  mention  of  median  forceps,  but  the  "high  operation"  is  defined  as  an 
operation  within  the  uterus,  whether  the  forceps  blades  were  applied  above 
the  pelvic  brim  or  within  the  excavation.  The  term  "low  operation"  is 
defined  as  an  operation  in  which  the  blades  are  applied  to  the  presenting 
part  when  it  had  reached  the  pelvic  floor  and  had  passed  through  the 
cervix. 

I  have  included  under  high  operations  a  large  number  of  cases  which 
were  really  median  operations,  in  order  to  be  consistent  in  the  earlier  and 
later  observations. 

The  classification  now  employed  is  as  follows: 

1.  High  Forcejps. — The  greatest  diameter  of  the  head  is  above  the  brim 
of  the  pelvis. 

2.  Median  Forceps. — The  greatest  diameter  of  the  head  has  passed  the 
brim  of  the  pelvis,  subdivided  into : 

(«)  Within  the  cervical  canal. 
(J)  Outside  the  cervical  canal. 

3.  Low  Forceps. — The  head  is  on  the  pelvic  floor. 

As  nearly  as  it  is  possible  to  determine,  the  median  operation  was  per- 
formed eighty-seven  times. 


110  REPORT   OF   THE   SOCIETY    OF   THE    LYING-IN    HOSPITAL. 

Incliulino;  most  of  the  iiiodian  operations  among  the  high,  forceps  were 
applied  as  follows: 

Iliirh 141  times. 

Low 153     '  * 

The  high  oi)eration,  therefore,  was  done  in  a  very  large  ])roportion  of 
the  total  number.  The  explanation  of  this  fact  is  the  routine  b}^  which 
women  are  allowed  to  remain  in  labor  until  it  is  almost  imperative  that 
some  active  interference  be  em])loved.  A  large  number  of  patients  who 
linally  deliver  themselves,  would  be  subjected  to  a  low  forceps  operation  in 
ordinary  private  practice.  Such  a  routine  is  perhaps  not  so  good  obstetrics, 
but  is  far  safer  under  the  conditions  than  a  more  indiscriminate  use  of 
the  forceps  would  be.  Even  after  it  has  been  determined  that  force]is 
would  be  advisable  in  a  given  case,  the  delay  in  reporting  to  the  IIos])ital 
ami  securing  the  attending  physician  to  operate,  not  infrequently  results 
in  a  s])ontaneous  delivery  while  the  preparations  for  a  forceps  delivery  are 
l)eing  made. 

The  total  number  of  294  observations  includes  not  only  actual  deliveries, 
but  all  cases  in  which  forcei)s  were  used  at  any  time  during  labor.  I  have 
se|)arated  the  latter  cases  and  tabulated  them,  as  follows: 

Cases. 

1.  Vertex   presentations,  in   which  forceps  were  attempted,  and   de- 

livery was  finally  accomplished,  after  a  podalic  version 10 

2.  Vertex  presentation,  in  which  forceps  were  attempted,  antl  delivery 

was  left  to  nature 1 

3.  ]>reech  presentation,   in  Avhich  the  forceps   were  applied  directly 

to  the  breech 1 

4.  Forceps  to  the  after-coming  head ;> 

Total 15 

In  twf)  of  the  three  cases  of  forceps  to  the  after-coming  head,  delivery 
was  accom})lisiied;  and  in  the  other,  after  traction  had  been  made,  the 
forceps  were  removed,  and  delivery  accomplished  by  manual  efforts. 

In  the  total  numl)er  of  294  cases,  the  presentation  was  as  follows: 


Vertex 270 

Face 5 

Shoulder .") 

Ijreech 1 


Brow 1 

Not  noted S 

Total 294 


Forceps  were  apj)li(Ml  directly  to  the  ])res('iitiiig  part  in  all  but  tlie  three 
cases  of  shoulder  presentations,  which  terminated  as  follows: 

In  one,  ce))ha]ic  version  Avas  ])erforme(l,  force))s  a|)|)li('(l  to  tlie  head, 
which  failed  to  engage;,  and  delivej-y  ^vas  effected  al'lei"  podalic  version.  Jn 
this  case,  both  mot  her  and  diiM  siii'vivc<l.  In  the  second  case,  podalic 
version   was   |t<Trornic<l.    dnrin;^-   which    the  cord    [o-ohipscd ;    IVji-ccjps  were 


STATISTICAL   REPORT   OF   FORCEPS   OPERATIONS. 


Ill 


applied  to  the  after-coming  head,  ^^  liich  was  finall}^  extracted  manually, 
resulting  in  tlie  recovery  of  the  mother  and  death  of  the  child. 

In  the  third  case,  podalic  version  was  performed,  and  the  after-coming 
head  delivered  by  forceps  through  a  rigid  cervix.  The  child  was  still- 
born and  the  mother  recovered. 

The  position  was  as  follows: 


L.  O.  A 
E.  O.  A 
L.  O.  P 
K.  O.  P 
K.  M.  P, 
L.  M.  P 


161 
49 
25 
41 


E.  Scap.  A 1 

E.      "     P 1 

L.      "      P 1 

Not  noted 10 

Total 294 


In  the  total  number  of  276  vertex  cases,  the  occiput  occupied  an  anterior 
position  in  210  cases,  and  a  posterior  position  in  66  cases.  Thus,  in  a  large 
number  of  cases,  the  posterior  position  of  the  occiput  was  the  cause  of  the 
delay,  and  an  indication  for  forceps. 

The  number  of  the  confinement  is  divided  as  follows  : 


I.  para 155 

IL  "  38 

III.  "  19 

lY.  "  21 

y.  "  14 

YI.  "  10 

YII.  "  8 

YIII.  "  4 


IX.  para 7 

X.     " 4 

XL     "     3 

XII.     "     1 

XIII.     "     1 

:N"ot  noted 9 

Total 294 


A  little  more  than  50  per  cent,  were  primipara. 


Age. 


Below  20 19 

20-25 156 

25-30 59 

30-35 29 


35-40 15 

40-50 4 

JS^ot  noted 12 

Total 294 


The  indications  for  forceps  include  a  large  number  of  accidental  com- 
plications. Nearly  all  the  indications  might  be  included  in  the  term, 
' '  delayed  tedious  labor, ' '  but  an  attempt  has  been  made  to  ascertain  the 
cause  of  the  delay,  whenever  possible.  As  the  term  is  used  in  the  table, 
the  delay  has  been  either  in  the  case  of  a  disproportion  between  the  size  of 
the  head  and  the  canal,  without  pelvic  deformity,  or  an  inherent  weakness 
of  the  uterine  contractions. 


112  KEPORT   OF   THE   SOCIETY   OF   THE    LYIXG-JX   HOSPITAL. 

The  indications  and  complications  luive  been  tabulated  together,  the 
complication  frequently  being  the  sole  indication. 

Indications  and  Complications. 

1.  Delayed  tedious  labor  (no  cause  for  delay  assigned) .  108 

2.  Uterine  inertia,  exhaustion 65 

3.  Strong  uterine  contractions,  no  progress 26 

4.  Deformed  pelvis 4-i 

5.  Eclampsia 8 

G.  Albuminuria  (threatened  eclam])sia) 5 

7.  Rigiility  and  oedema  of  cervix 7 

8.  Occiput  posterior,  failure  to  rotate 7 

9.  Large  head 5 

10.  lliemorrhage 6 

11.  Prolapse  of  the  cord 7 

12.  Face  presentation 2 

13.  Brow,  failure  to  extend 1 

14.  Prolapsed  arm 1 

15.  Tonic  uterine  contractions 1 

16.  "  Dry  labor  "  1 

Total 21>4 

I  have  thought  it  best,  in  making  this  table,  to  adhere  closely  to  the 
histories.  A])parent  inaccuracies  exist,  but  a  close  studv  shows  that  they 
are  only  apparent.  For  example,  there  were  five  face  presentations  in  all, 
but  only  two  appear  as  the  indication,  and  the  other  three  are  included — 
two  among  "  strong  pains,  no  advance,"  and  one  among  "  uterine  inertia." 
To  change  the  indications  and  include  the  two  apparently  uncomplicated 
face  ])resentations  among  the  others,  would  necessitate  a  change  in  the 
history  charts,  and  lead  to  endless  complications  and  confusion.  The 
indication  "  deformed  pelvis  "  also  needs  some  explanation.  There  were 
forty -four  such  cases  recorded,  as  follows: 

"  Contracted  or  deformed  " 27 

Justo-minor 8 

"  Flat  "  and  ''  promontory  ])i'<>inincnt  " 9 

Total 44 

In  but  thirty  of  tiicse  was  the  def(jrmity  marked,  as  has  been  shown  in 
an  article  elsewhere  in  this  Report.  In  the  remaining  fourteen  cases,  a 
diagnosis  of  dofonnity  was  questionable,  and  not  sustained  by  ]wlvic  meas- 
urements. The  histories  of  these  questionaljle  cases  contain  simply  a  state- 
ment, in  the  account  of  the  operation,  that  the  "  ])elvis  was  rather  small," 
or  "arch  narrow,"  or  "  promontory  jutted  forward."  They  were  usually 
consultation    cases,    with    no    actual    mc^asui-cments,   and    have   not   been 


STATISTICAL    REPORT   OF   FORCEPS   OPERATIONS.  113 

included  as  deformed  in  the  article  on  Pelvic  Deformity.  They  are  re- 
corded, however,  as  an  indication  for  forceps,  and  the  histories  have  not 
been  changed,  for  the  reasons  stated  before. 

The  condition  of  the  foetal  heart  at  time  of  operation  is  recorded  as 
follows: 

Cases. 

From  12(1  to  130 29 

''     130  to  140 102 

"     140  to  150 61 

"     150  to  160 14 

"     160  to  170 2 

"     170  to  180 1 

Foetal  heart  not  heard 85 

Total 294 

The  results  as  regards  the  mortality  for  children  have  already  been 
stated. 

It  may  be  repeated  in  conclusion,  that,  while  the  foregoing  statistical 
synopsis  develops  nothing  new  as  regards  the  technique  of  forceps  opera- 
tions, the  results  are  worthy  of  notice. 

The  forceps  which  are  commonly  employed  are  of  the  Elliot  pattern, 
and  have  given  general  satisfaction.  As  a  rule,  they  are  used  in  the  low 
operation,  and  have  frequently  been  applied  within  the  cervical  canal. 
The  axis-traction  forceps  of  Prof.  Alexander  Simpson  are  also  employed  in 
the  high  operation.  Forceps  of  various  other  patterns  have  been  used  by 
the  Hospital  from  time  to  time,  including  the  new^er  model  of  Tarnier  in 
difficult  deliveries,  and  the  forceps  of  Milne-Murray. 

The  statistics  show,  perhaps,  as  the  most  prominent  feature,  that  a  con- 
servative use  of  forceps  is  productive  of  good  results.  They  were  employed 
but  once  in  about  thirty-three  deliveries.  A  very  large  proportion  of  the 
total,  nearly  one-half,  w^ere  high  operations.  Notwithstanding  this  large 
proportion  of  high  operations,  and  the  frequency  of  complications,  the 
mortality  from  all  causes  was  but  a  fraction  more  than  two  per  cent. 

In  another  place  in  this  Report  the  surroundings  and  disadvantages  under 
which  these  operations  were  performed  have  been  explained  in  detail. 

Asepsis  of  the  operator,  instruments,  and  the  lield  of  operation, 
described  in  the  article  on  Morhidity  and  Moi^tality,  is  the  explanation 
of  results  which  compare  favorably  with  reports  of  operations  performed 
under  more  cleanly  surroundings. 

Squalor  and  filth,  while  of  unquestioned  disadvantage,  need  not  deter 
an  operator  from  interfering  in  the  course  of  labor  when  forceps  are 
clearly  indicated,  promled  facilities  can  be  had  for  what  may  be  called 
local  antisepsis. 


THE   PEEMATUEE   INTEKRUPTION   OF  PKEGNANCY. 

By  James  Clifton  Edgar,  M.D. 

Introduction. 

^^E  intend  in  tliis  article  to  make  a  study  of  the  prematurel}''  inter- 
rupted pregnancies  which  occurred  in  the  first  10,000  cases  of  confinement 
in  the  practice  of  this  Hospital  during  the  period  from  January  27,  1800, 
to  February  28,  1896. 

The  histories  of  these  10,000  cases  show  that  there  was  among  them  a 
total  of  G35  premature  interruptions  of  pregnancy.  In  the  three  Medical 
ltej)orts  of  the  Hospital  previously  ])ublished,  no  mention  has  been  made  of 
these  635  cases  of  the  untimely  interruption  of  pregnancy,  other  than  in  a 
general  way,  so  that  we  now  purpose  to  make  a  critical  study  of  the  entire 
number. 

Character  of  tue  Cases  Studied  in  this  Article. 

The  practice  of  this  Hospital,  during  the  period  covered  by  this  article, 
lias  been  almost  exclusively  among  tlie  ])<)()rest  of  the  Polish  Jews,  Ger- 
mans, and  Russians  of  the  tenement-house  district  of  tlie  lower  East  Side 
of  this  city. 

These  ])eo))le  constitute  an  exceedingly  primitive  class,  who  are  not  only 
quite  ignorant  of  the  first  ]n'inci))les  of  cleanliness,  but  who  consider  it 
the  proper  thing  to  neglect  an  untimely  interruption  of  pregnancy,  so 
that  when  the  Hospital  has  l)een  applied  to  for  aid,  it  has  usually  been  late 
in  the  course  of  the  case,  and  for  some  serious  comj)lication  as,  for  example, 
persistent  haemorrhage,  or  local  or  general  septic  coiulitions. 

This  is  evident  from  the  fficts,  as  a  critical  study  of  our  (535  cases  shows 
that,  in  most  instances,  the  sym])toms  had  alnjady  existed  for  some  time 
when  tJie  case  was  lirst  Ijrought  to  the  notice  of  the  Hospital,  and  that  the 
largf!  j)roportion  of  cases,  when  they  were  seen,  were  of  the  incomplete  or 
neglecte<l  variety  of  the  prem.'iture  interru]ition  of  pregnancy. 

Thus,  as  regards  the  <hir;itioii  of  the  syiii|)toins,  ;it  the  time  when  the 
Hospital  ])hysician  w;is  lirst  suiiiinoiied  to  the  ease,  we  liiKJ,  from  oui-  analy- 
sis, the  following: 


THE   PREMATURE   INTERRUPTION    OF   PREGNANCY.  115 

Duration  of  Symptoms  "when  First  seen  by  the  Hospital. 


Average  duration 
Longest  ' ' 

Shortest  " 


EARLY    abortions, 

129  Observations. 


3  days  22  hours. 
3  weeks. 
10  minutes. 


LATE    abortions, 

57  Observations. 


6  days  19  hours. 
T  weeks. 
1  hour. 


Again,  for  example,  the  table  setting  forth  the  character  of  the  early 
abortions  (see  Definitions),  when  first  seen,  indicates  the  following : 

Complete  early  abortions 14 


Incomplete  " 
Inevitable  ' ' 
Threatened  " 
JSTot  noted    " 


162 

48 

6 

12 


Total 242 

As  the  foregoing  table  shows,  a  large  proportion,  nainely,  162,  of  the 
early  abortions  were  of  the  incomplete  variety  when  the  Hospital  physician 
was  first  summoned;  48  were  inevitable,  and  in  only  6  instances  were  the 
services  of  the  Hospital  physician  demanded  before  the  partial  or  com- 
plete expulsion  of  the  ovum. 

Several  interesting  facts  will  be  noted  from  a  study  of  the  first  of  the 
above  tables. 

In  the  first  place,  in  both  the  early  and  late  abortions,  the  average 
time  from  the  onset  of  the  symptoms  to  the  application  to  the  Hospital 
for  aid,  was  over  three  days ;  and,  in  the  second  place,  in  the  late  abortions 
(see  Classification  and  Definitions),  this  same  interval  was  nearly  twice  as 
long  as  in  the  early  abortions,  as  one  would  naturally  suppose  would  be 
the  case,  in  \dew  of  the  larger  amount  and  greater  frequency  of  the  haem- 
orrhage in  interrupted  pregnancies  occurring  in  the  first  third  of  gestation. 

Since,  as  we  have  shown  in  the  preceding  paragraph,  most  of  our  cases 
of  abortion  have  been  seen  late  in  the  progress  of  the  process,  some  of  the 
statistics  of  this  article  cannot,  in  fairness,  be  compared  with  those  of  the 
large  maternities  of  France  and  Germany,  in  which  many  of  the  cases 
Avere  under  observation  from  the  very  onset  of  the  symptoms. 

The  following  tables  of  attendance  in  early  and  late  abortions  and  in 
spontaneous  premature  labor  cases  also  emphasize  the  above  statements: 

Attendance  in  Early  Abortion  Cases. 

ISTumber  of  cases  confined  by  the  Hospital 88 

"         "     "      unattended 143 

"         "     "      not  noted  on  histories 11 

Total 242 


IIG  REPORT   OF   THE   SOCIETY    OF   THE    LYING-IN    HOSPITAL. 


Attendance  in  Late  Abortion  Cases. 

Number  of  cases  coiifiiUHl  by  the  Hospital 60 

"       '•      '•      unattiMukHl 99 

' not  nottnl  on  histories 16 

Total 175 


ArrENDANCE  IN  Spontaneous  Premature  Labor  Cases. 

Number  of  cases  confined  by  the  Hospital 170 

"       "      "      unattended 28 

"       "      ''      not  noted  on  records 20 

Total 218 

It  is  not  alone  in  maternity  hospitals,  but  in  private  practice  as  well, 
that  histories  and  reported  cases  of  interrupted  pregnancies  would  prove 
of  the  utmost  value;  because,  as  Winckel  has  observed,  more  interrupted 
jH-egnancies  occur  in  private  practice  than  ever  come  to  hospitals  for 
treatment,  and  such  cases  are  more  favorable  for  active  interference,  because 
seen  earlier,  and,  moreover,  the  effect  of  an  early  curettage  upon  subse- 
quent uterine  disease  and  conception  can  be  critically  observed. 

These  635  cases  of  the  premature  interruption  of  pregnancy  treated  by 
this  Hosjiital  are  from  among  the  abject  poor,  Avho,  by  reason  of  their 
poverty,  are  unable  to  procure  the  services  of  skilled  medical  assistance, 
and  who,  unless  treated  in  some  such  service  as  this  Hospital  carries  on, 
would  receive  little  treatment,  would  be  neglected,  or  would  have  no  atten- 
tion whatever  in  their  confinements. 

These  individuals  are,  in  the  main,  foreigners,  or  but  recently  natural- 
ized, and  are,  of  necessity,  of  the  tenement-house  population,  as  is  sliown 
by  the  accompanying  figures. 

Thus,  of  the  first  8,0()8  cases  of  confinement  treated  by  this  Hospital, 
we  find  that  there  were: 


5,39.")  Russians, 
724  Native  Born, 
583  Austrians, 


346  Germans, 

211  Poles, 

13S  Hunirarians, 


and  tlie  remaind<'i-  ItaliMiis,  lioutnclians,  Swedes,  etc. 

it  will  be  seen,  thciHifore,  that  it  is  nniong  llx;  foreign-l>oiii  population, 
and  cspfcialiy  among  the  Russians,  Austrians,  Germans,  and  ]*olish- 
IIcl)rews,  tliat  these  cases  have  be(.'!n  treated. 

Moreover,  the  above-cited  1(»,000  cases  of  confinement  were  treated  in 
th<;ir  own  homes,  situaUid  in  i\u)  tcncinciit-house  district  of  th(;  lo\v<;r  East 
Si'h'  of  tlio  city. 


THE    PREMATURE    INTERRUPTION   OF    PREGNANCY. 


117 


I'he  tenement-house  census  for  1893  shows  that  the  most  densely  popu- 
hited  areji  in  New  York  City  is  situated  in  this  district  covered  by  the  Hos- 
pital Service  in  the  Eleventh  AVard,  and  is  bounded  by  Second  Street, 
Columbia,  Rivington,  and  Clinton  Streets,  and  is  known  as  Sanitary  Dis- 
trict A  of  the  ward. 

This  area  contains  32  acres,  has  a  population  of  25,015,  or  about  800 
persons  to  the  acre,  equal  to  a  population  of  513,901  to  the  square  mile. 

It  is  interesting  to  note  that  the  density  of  population  in  the  above- 
cited  area  has  actually  increased  during  the  past  few  years. 

Thus,  in  the  Annual  Report  of  the  Kew  York  City  Board  of  Health 
for  1894,  p.  101,  we  find: 


YEAR. 

WARD. 

SANITARY   DISTRICT. 

DENSITY    PER    ACRE. 

1890 

11th. 
11th. 
11th. 

A. 
A. 
A. 

763.59 

1893 

800.47 

1894  (estimated) 

986.4 

Previous  to  1890,  Germans  and  Bohemians  predominated  in  this  dis- 
trict; after  1890,  Germans  and  Hungarians.     (Vital  Statistics,  p.  101.) 

Again,  during  the  past  thirty  years  the  greatest  density  of  population 
per  acre  was  to  be  found  in  the  Sixth,  Tenth,  and  Eleventh  Wards,  all  of 
which  are  included  in  the  tenement-house  district  of  the  lower  East  Side, 
above  referred  to. 

Thus,  the  following  table,  taken  from  the  Report  of  the  Tenement- 
House  Committee  to  the  New  York  State  Senate  (1894),*  indicates  at  a 
glance  the  progressive  increase  of  population  in  these  wards  during  the 
thirty-four  years : 


YEAR. 

WARD. 

DENSITY    PER    ACRE. 

1860 

6th. 
11th. 
10th. 
10th. 
10th. 

310.4 

1870 

327.7 

1880 

432.3 

1890 

525.6 

1894  (estimated) 

701.9 

The  New  York  State  Census  for  1 892  shows  that  the  seven  most  densely 
populated  blocks  in  this  city  have  each  a  population  exceeding  3,000  per- 
sons to  the  block,  and  an  aggregate  population  of  22,970. 

*  Eeport  of  the  Tenement-House  Committee  to  New  York  State  Senate,  1894,  by 
F.  E.  Pierce. 


118  REPORT   OF   THE   SOCIETY    OF   THE    LYING -IX    HOSPITAL. 

Tlie  fii*st  of  these  is  in  the  district  covered  by  the  service  of  this  Hos- 
pital, and  they  have  the  foHowino-  boundaries: 

Popuhxtion. 

2d  and  'MX  Streets,  Avenues  B  and  C 8,532 

48th  and  40th  Streets.  10th  and  11th  Avenues 3,517 

48th     ••     4i>th       '*           Oth     "     lOth         ^'       3,365 

40th    "    50th      "         10th    "     11th         "       3,339 

44th     '*    45th       "         10th     "     11th         "       3,151 

52d      "     53d         "           9th     ''     loth         "       3,040 

39th     •'    4(tth       "           9th    ''     lotli         "       3,026 

Aggregate  population 22,970 

Further,  the  same  census  sliows  that  seven  blocks  in  the  immediate 
vicinity  of  the  original  administi'ation  building  of  this  Lying-in  Service 
(314  Broome  Street),  in  Avhich  district  the  uuijority  of  the  cases  included  in 
this  article  were  treated,  have  each  a  population  of  2,500  individuals  or 
over,  and  an  aggregate  population  of  18,603. 

These  blocks  and  their  po})ulation  are  as  follows: 

Population. 

Ridge,  Pitt,  East  Houston,  and  Stanton  Streets 2,985 

Market,  Pike,  Madison,  and  Henry  Streets 2,503 

Market,  Pike,  Madison,  and  Monroe  Streets 2,586 

Pike,  Rutgers,  Madison,  and  Monroe  Streets 2,662 

Madison,  Monroe,  Scammel,  and  Jackson  Streets  ....     2,500 

Rivington,  Stanton,  Willett,  and  Pitt 2,548 

2d  and  3d  Streets,  Avenues  A  and  J} 2,819 

Aggregate  population 18,603 

The  most  densely  populated  district  is  bounded  by  Second  Street,  Riv- 
ington, Columbia,  and  Clinton  Streets;  it  covers  32  acres,  has  a  population 
of  25,615,  or  800  per  acre,  according  to  the  Tenement-House  Census  of 
1893.     This  makes  a  ])opulation  of  513,901  persons  to  the  square  mile. 

Some  interesting  figures  concerning  the  inhabitants  of  a  portion  of 
the  district  covered  l)y  this  Hosjiital  are  to  be  found  in  the  latest  special 
r(;jK)i-t  of  the  Commissioner  of  Labor  at  AVashington. 

Tlie  tenement-hous(;  districts  investigated  are  those  of  New  York, 
Chicago,  l)altimore,  and  Pliilad('l])hia,  and  these  by  sam])le,  as  it  were. 
Thus,  in  New  York,  for  instance,  tlu^  disti'icts  chosen  were  west  of  the 
Bowery,  \vholly  within  the  Sixth  ;md  Fourteenth  Wards,  and  made  up  of 
an  almost  cxcbisivc  Italian  p<)j)ulati<)n,  though  it  included  fliinatown. 

Directly  adjoining  this  district,  to  the  east,  across  the  Bowery,  is  one 
in  which  most  of  the  cases  treated  in  this  Ilcport  reside,  a  people  exclu- 
sively iiussian  Hebrew;  and  just  U>  the  south,  on  Cherry  Hill,  a  character- 
i.stic  Irish  population. 

Neither  of  these  two  latter  districts  found  a  place  in  the  above  Report, 
which  in  some  im|)ortant  particulars  thisy  would  have  modified,  but  all 
these  are  included  in  the  service  of  this  Ilosjutal. 


THE   PREMATURE   INTERRUPTION   OF   PREGNANCY.  119 

The  investigations  of  the  Commissioner  sought  the  plain  facts  of  slum 
life,  and  such  as  might  be  arranged  for  statistical  study. 

Foreigners  Predominate. — In  New  York  the  foreign-born  number  42.28 
per  cent,  of  the  total  population  of  the  city,  but  in  this  tenement-house 
district  studied,  it  reaches  62.58,  an  excess  of  20.35  per  cent.  Persons  of 
foreign  parentage  are  largely  in  excess,  namely,  95.23  per  cent,  for  this 
district,  to  80.46  per  cent,  of  the  whole  city;  in  other  words,  only  4.77 
per  cent,  were  of  native  parentage.  54.61  per  cent,  are  males,  and  45.39 
])er  cent,  are  females.  Tliis  preponderance  of  the  men  perhaps  accounts 
for  the  greater  wickedness  of  this  district,  as  the  police  records  of  arrests 
show  a  proportion  of  1  in  6  for  this  district,  and  1  in  18  for  the  entire  city. 

They  are  a  Conjugal  People. — They  marry  early  and  have  larger  families 
than  those  who  are  better  off  as  to  residence.  Single  blessedness  is  unpop- 
ular, widowers  are  scarce;  some  widows  were  reported,  but  fewer  than 
the  proportion  shown  by  a  census  of  the  whole  city;  divorce  is  all  but 
unknoAvn,  only  .01  per  cent,  of  males  and  females  were  reported  as 
divorced. 

Illiteracy. — For  New  York,  as  a  whole,  the  percentage  of  illiterates  is 
1.16  of  the  whole  native-born  population,  and  14.06  of  the  foreign-born, 
the  percentage  for  both  being  7.69,  while  for  the  district  under  discussion, 
the  percentage  of  native-born  who  are  illiterate  is  7.20,  and  of  the  for- 
eign-born, 57.69,  being,  for  both,  46.65.  Fortunately,  the  illiteracy  is 
almost  entirely  confined  to  adults. 

There  are  more  women  who  cannot  read  than  men,  and  in  point  of 
succession,  the  most  ignorant  are  the  Italians,  then  come  the  Russians,  then 
the  Poles. 

Croioded  Tenements. — Comparing  similar  tenement-house  districts  of 
Baltimore,  Philadelphia,  New  York,  and  Chicago,  New  York  has,  by  far, 
the  greatest  crowds  under  one  roof,  but  the  percentage  of  crowding  in  the 
rooms  is  smaller  than  in  the  other  cities  named;  thus,  the  percentage  of 
families  living  in  one  room  is  13.16  in  Baltimore,  12.10  in  Philadelphia, 
5.87  in  Chicago,  and  5.62  in  New  York. 

It  should  be  added  that  the  houses  are  larger  in  Chicago  and  New  York 
than  in  the  other  cities  named. 

Sanitary  Cleanliness. — Only  2.33  per  cent,  of  the  families  have  access 
to  a  bathroom,  the  percentage  for  the  similar  districts  being,  in  Baltimore, 
7.35;  in  Philadelphia,  16.90;  in  Chicago,  2.83;  96.67  per  cent,  of  the  houses 
of  the  district  in  New  York  have  no  bathrooms,  and  the  average  number 
of  persons  compelled  to  use  the  same  water-closet  or  privy  is  10.52  persons 
(in  Philadelphia  the  number  is  6.86). 

Classification  and  Definitions. 

It  will  be  well  at  the  outset,  before  entering  upon  a  closer  examination 
of  the  cases  of  interrupted  pregnancy  included  in  this  article,  to  set  forth 
clearly  our  classification  of  these  cases,  and  come  to  a  definite  understand- 
ing of  the  definitions  of  the  terms  here  used. 

We  find  that  most  of  the  German  textbooks  of  obstetrics,  with  the 


120  KEl'OHT   OF   THE   SOCIETY    OF   THE    LVING-IN    HOSPITAL. 

exception  of  tliose  of  A.  ^lartin  aiul  AViiickel,  look  upon  the  separation 
of  abortion  and  immature  labor  as  unjnstiiiable,  and  consider  the  period  of 
viability,  at  the  end  of  the  seventh  month,  as  the  only  admissible  point 
of  division. 

It  will  be  found,  moreover,  upon  reference  to  most  of  the  French  text- 
books, that  thev  understand  the  term  acoriemeni  to  extend  to  the  end  of 
the  seventh  month  of  intrauterine  gestation. 

Afcordinu-  ti>  A>it  (^[idler's  Handbook),  all  cases  occurring-  within  the 
first  t\venty-eig-ht  weeks  of  ]ireg-nancy  should  be  grou[)ed  under  the  term 
ahortion,  because,  uj)  to  this  tinu\  })ractically  no  i-egai'd  need  be  paid  to  the 
life  of  the  fVetns,  which  may  be  looked  upon  as  practically  lost. 

In  former  times,  the  ditferences  in  the  course  of  the  prenuitni'c  inter- 
ru])tions  of  pregnancy  led  to  a  division  into  abortion,  immature  labor,  and 
])i-emature  lal)or;  but  Ave  no  longer  make  the  first  two  distinctions,  because 
in  the  coui-se  of  abortion  occurring  even  in  the  first  three  months  of  gesta- 
tion differences  may  be  observed  which  are  so  great  that,  even  here,  one 
would  be  jnstified  in  making  additional  divisions  and  classi  11  cations.  For 
exam])le,  some  of  the  French  writers  speak  of  "ovular  aboi-tions,"  occur- 
ring in  the  first  six  weeks  of  gestation;  "  embryonal  abortions,"  occurring 
from  the  eighth  to  the  twelfth  week  of  gestation ;  and  of  "  fa?tal  abortions," 
occurrino;  from  the  twelfth  to  the  twentv-fourth  Aveck  of  gestation. 

In  general,  Ave  may  place  the  time-limit  of  the  term  ah(>iilo)i  at  the 
twenty-eighth  Aveek  from  the  beginning  of  the  last  menstrual  period;  but 
Ave  nuist  not  lose  sight  of  the  fact,  on  the  one  hand,  that  foetuses  may  not 
be  vialjle  after  this  time  (in  the  first  place,  because  the  calculation  of  ju'eg- 
nancy  Avas  faulty;  and,  secondly,  because  the  resisting  jxnver  of  the 
foetus  is  at  a  Ioav  point  at  about  the  tAvonty-eighth  Aveek);  on  the  other 
hand,  that,  exceptionally,  a  child  born  previous  to  the  calculated  tAvent}'- 
eighth  AA^eek  of  gestation  may  live.  Ahlfeld^  is  among  those  who  believe 
that  tlie  assum]ition  that  children  born  before  the  end  of  the  seventh 
lunar  month  are  non- viable,  is  entirely  too  arbitrary.  He  quotes  many 
cases  in  ]iroof  of  the  fact  that  children  may  survive,  even  if  born  before 
the  com])letion  of  the  twenty-eighth  Aveek,  and  he  warns  us  not  to  allow 
tliis  arlntrary  division  to  deter  us  from  making  every  possible  effort  at  our 
command  to  resuscitate  a  premature  infant,  no  matter  Avhat  the  supposed 
period  of  gestation  or  develo])ment  of  the  fcetus,  so  long  as  there  are  any 
signs  of  life.     Lusk  subsecpiently  expressed  himself  to  the  same  effect. 

The  marvellous  results  obtained  in  the  Paris  nuiternities,  notably  under 
Hudin  and  Tarnier,  by  the  use  of  the  couA'euse  and  gavage,  show  that  a 
cei'tiun  pro])oi'tion  of  children  born  at  the  twenty-seventh,  twenty-sixth, 
twcnty-lifth,  and  even  twenty-fourth  Aveek  of  gestation  has  been  preserA'ed, 
l>udin  claims  to  have  saved  ;;(i  jx-r  cent,  at  the  tAventy-fouiMi  week. 

Although  the  ]»eri(jd  of  viai)ilitv  has  been,  and  may  in  the  future  be 
still  further,  reduced,  undei-  favorabh!  ciirumstances,  still,  since  the  pro- 
portion of  iidanls  saved  befoic  the  tAventy -eighth  Aveek  is  as  yet  small,  and 
the  good  r(;sults  are  eonlined  to  maternity  hospitals;  and,  monjover,  since 
our  417  cases  of  interrupted   pregnancies  falling  in   the  lirst  twenty-eight 


THE   PREMATURE    INTERRUPTION    OF    PREGNANCY.  121 

weeks  of  gestation  liave  all  been  treated  in  their  own  homes  in  tenement 
houses,  where,  heretofore,  the  use  of  the  couveuse  and  gavage  has  not  been 
practicable,*  therefore  we  have  seen  fit  still  to  retain  the  end  of  the 
twenty-eighth  week  as  the  period  of  viability  and  tlie  point  of  division 
between  abortion  and  ]n'ematnre  labor. 

For  the  foregoing  reasons,  and  also  as  a  matter  of  convenience,  the 
Medical  Board  of  this  Hospital  recently  decided  to  classify  all  cases  of  the 
pi-emature  interruption  of  pregnancy  under  two  main  heads,  as  follows: 

Classification  of  the  Pkemature  Intekruption  of  Pregnancy. 

1.  Abortions. 

2.  Premature  labors. 

1.  Ahortions  are  those  premature  interruptions  of  pregnancy  occurring 
l)efore  the  completion  of  the  seventh  month  of  intrauterine  gestation; 
namely,  the  first  six  and  three-quarter  months,  or  the  first  twenty-seven 
weeks. 

2.  Premature  labors  are  those  premature  interruptions  of  pregnancy 
taking  ]3lace  at  and  after  the  completion  of  the  seventh  lunar  month, 
(twenty-eighth  week) ;  namely,  from  the  twenty-eighth  to  the  tliirt3^-eighth. 
week. 

In  this  article,  however,  for  clinical  and  anal3^tic  purposes,  it  has  been 
deemed  advisable  to  make  a  further  subdivision  of  the  417  cases  of  inter- 
rupted pregnancy  occurring  before  the  completion  of  the  twenty-eighth 
week,  in  order  that  a  closer  and  more  profitable  study  may  result.  So 
that,  for  purposes  of  convenience  solely,  we  have  divided  these  417  cases 
falling  under  the  definition  of  ahortion  into — 

(1)  Early  abortions. 

(2)  Late  abortions. 

We  include  under  the  term  early  ahortion  those  instances  of  the  prema- 
ture interruption  of  pregnancy  occurring  in  the  first  three  months,  or 
twelve  weeks,  of  uterine  gestation. 

Cases  of  late  ahortion  are  those  falling  within  the  period  from  the 
beffinnine:  of  the  fourth  to  the  end  of  the  seventh  month.  The  term 
premature  lahor  covers  the  remaining  cases  of  the  premature  interruption 
of  pregnancy.  Our  635  cases  of  the  premature  interruption  of  pregnancy 
therefore  include: 

Cases. 

Early  abortions 242 

Late  abortions 175 

417 
Premature  labor 218 

Total 635 

*  Since  the  opening  of  the  main  Hospital  buikling  in  November,  1894,  premature 
infants,  when  possible,  are  transferred  to  the  Hospital  for  couveuse  treatment. 


l'^-?  KEPORT    OF    IHK    SOCTETV    OF    THE    LYING-IN    HOSIM'J'AL. 

Our  arbitrary  division  ol"  the  cases  of  abortion  into  those  of  early  and 
late  abortion  has  been  made  use  of  because,  clinically,  in  most  instances, 
the  i)rogress  of  an  early  abortion  can  be  sharply  differentiated  from  that 
of  a  late  abortion.  Before  the  beginning  of  the  fourth  month,  the  clinical 
])ictare  presented  by  the  em])tying  of  a  i)regnant  uterus  is  usually  alto- 
gether dilferent  from  an  expulsion  of  the  uterine  contents  subsequently. 

During  the  tirst  three  months  the  ovum  is  expelled  as  a  Avhole,  or 
broken  up,  with  more  or  less  ])rofuse  haemorrhage,  hence  it  is  that  usually 
but  a  siuii'le  staii'e  of  labor  can  be  recognized;  while  after  the  third  month 
the  course  of  labor  corresponds  more  nearly  with  parturition  at  term,  and 
in  most  instances  tliree  stages  of  labor  can  be  distinctly  differentiated. 

A  study  of  our  histories  bears  out  this  fact,  for  in  the  242  early  abor- 
tions we  find  no  record  of  the  stage  of  labor  present  \vlien  the  case  Avas 
first  seen  by  the  Hospital  ])hysician;  while  in  the  175  late  abortions  we 
find  lifty  observations  upon  the  stage  of  labor  present  at  the  time  the 
physician  from  the  Hospital  first  visited  the  patient. 

Stage  of   Labor  in  amirji    Late  Aboktions  wekk   Fikst  A^isited  jsy  the 

,  Hospital. 

Cases. 

Visited  l^y  the  Hospital  in  the  first  stage 25 

second  stage 12 

''  '*  '•  '•        third  stage 13 

Not  noted  on  the  histories 125 

Total 1 75 

Further,  it  is  (juite  true  that  during  the  empt3'jng  of  the  pregnant 
uterus  in  the  fourth,  fifth,  and  sixth  months  of  pregnane}',  haemorrhage 
may  and  does  occur,  and  the  ovum  may  be  expelled  intact,  yet  this  is  the 
excejition  rather  than  the  rule,  and  therefore  does  not  militate  against  our 
arbitrary  classification.  Moreover,  owing  to  the  luiMnoi'i-liage  which  is  so 
constantly  present  in  the  first  three  months,  the  trt^atment  is  often  differ- 
ent, to  a  certain  extent,  from  that  employed  after  that  time. 

In  c<jmparing  the  course  of  labor  in  late  al)oilioiis  and  ]))'ei)iatiii'e  labor, 
we  find  that,  clinically,  tlie  most  iin])ortant  distinguishing  feature  between 
the  two  is  the  course  <4"  tlx;  third  stage  of  labor.  After  tlu^  end  of  the 
twenty-eightli  week,  the  tliii'(l  stage  of  laboi'  dilVers  in  no  way  tVoni  the 
tliird  stage  at  fid!  term ;  while  l)efo)'e  the  seventh  month,  the  thii'd  stage 
may  continue  days  and  weeks  unless  its  course  is  artiiicially  terminated. 
(See  Treatment.) 

Finally,  as  a  matter  of  convenience  and  foi-  clinical  study,  the  sulxlivi- 
sion  of  the  term  ahnrfion  is  jiistifialile  and  desii'able,  because  in  the  iirst 
three  months  the  oviiin  with  tlu;  placenta  are  often  ex])e lied  together,  <))■ 
the  cscajx;  of  the  fcjctus  is  unobserved  Ijecause  of  its  nnnute  size.  Henc(^, 
tliere  is  jiractically  no  point  at  wliich  we  can  date  the;  onset  of  the  third 
stage  of  labor.     After  the  tliird  month,  and  the  formation  of  the  ])lacenta, 


THE    PREMATURE   INTERRUPTION"   OF   PREGNANCY.  123 

Oil  the  other  hand,  our  records  indicate  that  the  third  stage  is  a  distinct 
period  in  the  course  of  the  premature  enipt34ng'  of  the  uterus. 

This  chissification  into  early  abortions,  late  abortions,  and  premature 
labors,  although  purely  artificial,  we  ado])t  in  this  article  because  of  the 
differences  in  the  pathology,  s3miptomatology,  and  treatment  of  the  three 
groups  thus  designated. 

For  the  foregoing  reasons,  therefore,  we  deem  it  most  advisable  to 
adopt  this  purely  artilicial  division  of  the  premature  interruption  of  preg- 
nancy, designating  the  accident  occurring  in  the  first  three  months,  or 
twelve  weeks,  of  uterine  gestation  an  early  abortion;  that  occurring  in  the 
fourth,  fiftli,  and  sixth  and  three-quarter  months,  or  twenty-seven  weeks, 
a  late  abortion;  and,  finally,  that  falling  in  the  period  from  the  twent}^- 
eightli  week,  the  generally  accepted  period  of  viability,  to  the  thirty- 
eighth  week,  or  to  the  time  Avhen  the  measurements  of  the  foetus  are  prac- 
tically indicative  of  maturity,  premature  labor. 

Statistical  and  Classification  Tables. 

For  convenience'  sake,  and  to  further  our  subsequent  study  of  these 
635  cases  of  the  premature  interruption  of  pregnancy,  we  have  divided 
them  in  three  statistical  tables,  according  to  our  definitions  (see  Classifica- 
tion and  Definitions),  and  placed  these  three  tables,  of  early  abortions, 
late  abortions,  and  spontaneous  premature  labor,  respectively,  at  this  por- 
tion of  our  report. 

Early  Ahortions. — By  reference  to  the  table  of  our  212  cases  of  early 
abortion,  it  will  be  seen  that  for  convenience  of  reference  Ave  have 
arranged  in  parallel  columns  the  information  obtained  from  a  laborious  and 
critical  examination  of  each  separate  history  chart,  upon  the  following 
points : 

1.  Confinement  number. 

2.  Birthplace. 

3.  Age. 
■i.  Para. 

5.  Month  of  gestation. 

G.  Previous  interruptions  of  pregnancy. 

7.  By  whom  delivered. 

8.  Character  of  the  abortion  when  first  seen. 

9.  Duration  of  the  symptoms  when  first  seen. 

10.  Previously  attended  by  whom. 

11.  Condition  of  ovum. 

12.  Condition  of  embryo. 

13.  Haemorrhage. 

li.  Interval  between  first  visit  by  Hospital  physician  and  operation. 

15.  Temperature  at  various  periods. 

16.  Treatment. 

17.  Complications. 

IS.  Discharge;  day  of  puerperium  and  condition. 


1'2A  REPORT   OF   THE   SOCIETY    OF   THE    LYING-IN    HOSPITAL. 

Zah  Ahortt'oii.-i.— The  table  of  the  17.">  cases  of  late  abortion  is  arranged 
very  much  in  the  same  manner  as  the  })receding',  only  that  here  additional 
space  is  given  for  the  presentation  and  condition  of  the  foetus,  and  for  the 
duration  and  termination  of  the  third  stage  of  labor. 

Sponfaneoffd  Premalure  Labor. — The  plan  of  this  table  is  practically  a 
repetition  of  the  one  for  late  abortions,  and  includes  218  cases. 

T/u'i<iti)n(1  Ahoiilons. — It  has  been  thought  best  to  leave  out  of  this 
Report  cases  of  threatened  abortion,  because  among  our  earlier  cases  the 
diagnosis  of  the  condition  has  in  several  instances  been  uncertain,  and  sat- 
isfactory histories  are  lacking. 

Among  our  recent  cases,  however,  more  exact  and  careful  observations 
are  recorded,  and  this  material  will  jn-ove  of  value  for  a  future  study. 

l*erioi1  of  (.Tcsiatoi/i. — In  our  al)ortion  cases,  both  early  and  late,  the 
period  of  gestation  at  whicli  the  accident  occurred  has  been  determined  from 
the  time  that  elapsed  from  the  last  menstrual  period,  from  the  size  of  the 
uterus,  and  from  a  microscopical  examination  of  the  ovum,  embryo,  or  foetus. 

As  wiU  be  observed  in  our  tables,  measurements  of  the  ovum,  embryo, 
and  fcptus  are  Avanting  in  most  of  our  cases  of  earl}''  and  late  abortions. 
Unfortunately  the  embryos  and  foetuses  of  our  abortion  cases  were 
destroyed  before  the  writer  could  obtain  access  to  them,  and  the  early 
histories  lack  records  of  weights  and  measurements. 

In  our  present  histories,  records  of  the  measurements  and  weights  are 
entered  at  the  time  of  the  abortion.  On  the  other  hand,  the  diagnosis  of 
the  period  of  pregnancy  in  our  premature  labor  cases  has  been  determined 
partly  from  the  duration  of  gestation  at  the  time  the  pregnancy  was  inter- 
ru]>ted,  but  especially  from  the  size  of  the  ftetus  at  the  time  of  its  expulsion. 
To  this  end  we  have  taken  into  consideration  (1)  the  length,  (2)  the  weight, 
and  (yj  the  measurements  of  the  foetal  head,  in  the  order  named. 

Regarding  the  head  measurement,  only  the  (1)  great  (occipito-mental) 
and  ( 2)  small  (suboccipito-bregmatic)  circumferences  have  been  used  as  a 
suliicient  index  of  the  size. 

V>\  reference  to  our  table  of  premature  labors,  it  will  be  observed  that 
in  l)ut  a  few  instances  are  the  above  measurements  lacking. 

EDfOATIONAT.    FkATURES. 

During  the  period  covered  by  this  Iteport,  namely,  a  little  over  five 
years,  there  have  resided  at  the  Hospital  buildings  9  resident  ])hysicia,ns, 
67  assistant  resident  ])hysicians,  2(»8  graduate  students,  and  1,315  under- 
graduate ]m])ils.  It  can  be  safely  stated  that  each  of  these  1,599  individ- 
uals jilaycd  a  greater  or  lesser  ])art  in  the  treatment  and  management  of 
the  0:^*5  untimely  interrupted  ])regnancies  here  studied. 

Further,  as  will  be  seen  I'loin  tlic  section  on  '^{"'rcatment,  .'{.''l  of  (tiii'  (i;>5 
cases  were  sui)jectcd  to  cui-cttagc;  and  as  this  o])('i'ation  is  ijcrfoi'mcd  only 
by  an  attending,  assistant  attending,  i-csidcnt,  assistant  resident,  or  gi-ad- 
uate  physician,  we  can  truthfully  state  tli;it  our  .■i;'>I  cases  of  curettage 
were  iM-rfoi-ineil  by  at  l(3<ist  15<i  difrciciit  dpi  r;it,(;rs. 


[ogle  rise  on  4tb  ilay. 


1 
s 

Birthplace 

i, 

8 

Germany. 

28 

CO 

Russia    ... 

a 

If 

U.  S 

Huiism-j-  .  3( 

■   iMiami::.': 

-? 

i 

Il.lits  Russia  — 

_'i 

19 

m 

XI 
30 

l.li;  Irdand  ... 
I.aiiclei-manv.. 

37 

UiljUMisia  .!.'! 

3 

^  i''i<.5ia"..:! 

M 
i\ 
23 
30 
34 
? 

31 

'.; 

20 
1! 

man 

|3,9.i4 
3,971 
»  3,985 

'u«ia  .... 

2h 

39 
12 
ii 
il 
3.1 

5 
5 

31 
2 
20 
3a 
3 
If 

1. 
II. 

0 

II. 

V. 

V. 

■M 

3( 

Ill 

I. 

11 

III. 

\v: 

V 

VI. 

V. 

X. 

VII. 

<l 

IX. 

XII 

31 

III. 

IV. 

.-. 

V. 

31 

VII 

31 

IV. 

IV 

+ 

111. 
I. 

4 

3  tlays  . . 
weeks 


7  days  . . . 
13  houi-s. 


Duration 
Symp- 


2  days . . 
1  day . . . 

weeks 


4  days . . . 

days . . . 
IShoure. 

1  montb. 


SYNOPSIS    OF    175    CASES    OF    LATE    ABORTIONS. 


TliMPERATUHE. 


2  weeks. 
1  day  . . . 


Few  hn 
1  day  . . 


1 

■3 
> 

] 
1 

1 

1 

1 
1 

1 
1 
1 
1 

1 

1 
1 

1 
1 

1 
1 

1 
1 

1 
1 

1 

1 

1 
1 

1 
= 

C 

% 

1 

1 

.1 
1 

1 

1 

1 
1 

1 

1 
1 

1 
1 
1 

1 
1 
1 
1 
1 
1 
1 

1 
1 
1 
1 

1 
1 
1 

1 

1 
1 
1 

1 
1 
1 

1 
1 

1 

1 

1 
1 

1 
1 
1 
1 

1 

1 
1 

1 
1 
1 
1 
1 
1 
1 
1 
1 
1 

1 

E 

1 
I 
1 

1 

1 

1 

1 

1 

1 
1 

1 

1 
1 
1 

1 
1 

1 

1 

1 
E 
S 
I 

1 

1 

I 
1 

1 

1 

1 

1 

1 

1 
1 
1 
1 
1 

1 
1 
1 
1 

1 

1 
1 
1 
1 
1 

1 

1 
1 

1 
1 
1 
1 
1 

1 

1 
1 

1 

1 

1 
1 

1 

1 
1 
1 
1 
1 
1 

1 
1 
1 
1 
1 
1 
1 
1 

D'lll 

1 

1 
1 

Si- 

1 

Weak-. 
Good. 


Weak. 
Good .' 


j  Retroflexed  (  „,.„„„ 
1  Reti-overted  r  "*^^'^"«  ■ 

Caked' breasts.  "  ^ 
Foul  lochia;  fever. 

Fever;  sepsis 

Case  left  to  midwife. 
Postpartum  ha^morrhag--. 
Sepsis;  b£emorrh.9thd,;/6U6?- 

Fever ;  bronchitis 

Fever;  sepsis. 

Postpartum  eiise. 

Fever;  unknowa  cause 

r ;  cause  unknown 
Fever;  sepsis 

Fever ;  sepsis 

Fever  ;  sepsis. 

jDca(/^  from  shock  , 

Fever ;  constipiition 

Fever;  coustipatiou.... 


Caked  breasts 


Fever ;  sepsis. 
Fever ;  sepsis . 
Fever;  sepsis... 


Fever;  sepsis;  albuminuria. 


Temperature  after  ( 


[fuse  &foul  f or  (i  days. 
th  d.  &  on;  bend  extraction;  lochia  pro- 


Case  turned  over  t 
Placenta  with  fiugi 


prii 


?  Dr.  immediately  after  oper. 


of  placenta. 

ion;  piae.  pnevia;  aceouchement  f orc6. 

Out  of  bed  12th  day. 

Placenta  pifevia;  death  of  mother;  nipt.utei-^is;  pod.  version. 
Postpartum  case;  ovum  delivered  iutact. 

Duly  temperature  rise,  3d  day;  no  fever  after. 

Cbild  died  soon  after  birtb. 

Private  doctor  called  In. 
Child  died  1st  day. 

iverneiu-  Hospital  ;  no  fc^^er. 

Hycfatiform  mole;  no  complications. 

Gouverneur    Hospital;    treated 
cellulitis. 

Caked  breasts;  child  lived  a  few  houi-s. 
No  subsequent  fever. 


Child  lived  a  few 


.  SlWithfem.  after  oper.;  refused  furtherti-eatmentSd  day; 
syphilis;  ulceration  in  pharynx;  cardiac  emphys. 

Everything 


N.  R.  =  No  record ;  L.  d.  =  Labor  day. 


123 

LATE    ABORTIONS 

.—(Continued.) 

Stage                  j 

g 

:; 

i  ! 
1  1   ■ 

3    fk      i 
para.  ^ 

III 

11.4 

ik         I 

Pi 

fcetus.                                      ce^ 

A-                                    c 

Duration      ^ 
of          ^ 

Temperature. 

Tkeament. 

i 

. 

f 

1 
1 

4,053 

Birthplace,  t 

SEEN^  I>"ration| 

i 

Time 
Between 
-     Pii-st 
S  Visit  and 
3     Opern- 
a      tion. 
; 

J 
5 

Gauze 

He- 
mained 
How 
Lon^. 

s 

Complications. 

Remarks. 

1 

toms      c 

When     = 

First      .jJ 

.^                 Seen.     ^ 

s     1 

1 

If 

%        ^  -  ■ 
1        lis 

3               1        ^ 

lei    1     li 

ill  I  II 

o.           Third 

«        Stage  of    i' 

5          Labor.     S 

If                     ^ 

11         1 

1 
1 

1 
0 

< 

1 

0 
s 
< 

S 

isl 

■gi- 
a 

1 

1 
s 

> 

i 
1 

2 

p 

! 

j 

a 

i 

i 

1 

I 

1 

1 

m 

tussia  ....  3.. 

1               1  day  ... . 

1                 I 

1 

At  once. 

Good.. 

91 

1,103 

....3C 

VI.  6               1 
VIII.  3J 
IV.  6 

1           1  hour. . . 

1               13  hours. 

1           7  weeks  . 

1 

1 

1              1 

1 

1 

8 

Placenta  remarkably  fatty. 

92 
93 

4,107 
4.198 

"       ....3t 
....3" 

1                 1 

1 

2  hrs  — 

101.8 

1st  d. 

1  day ... . 

1 

9 

Fever ;  sepsis 

Hydrocephalus;  no  curetting;  plac.  almost  entirely  fattv 
Single  rise  in  temp.  'M  and  4tli  day;  out  of  bed  6th  day. 

94 

4,343 

....3 

U.S 1 

Kussia  ....  i 

!-5 

1 

1 

r     .1 

98.5 

101.4 

4th  '■ 

Few  hrs. 

7 

Fever ;  sepsis 

95 
96 

4.284 
4,309 

I.  o 
VUI.  4              I 

1 

3  days . . . 

1               I 

12    "'.'.'.'. 

101.2 

101.2 

0th" 

1 

9 

"    ;; 

Fever ;  constipation 

Singrle  rise  in  temp,  after  operation,  on  Gth  day;  bleedini; 

'97 

4,320 

II.  3(            1 

1                    1 

1 

during  entire  pregnancy. 
Extraction  of  breech. 

9S 

4.597 

'".'.2 

IV.  6(         2    1 

1 

1 

4  inch. 

3  lbs.            1 

1      33niin.  ... 

7 

99 
100 
101 
102 
103 
104 
105 
106 

4.608 
4.672 
4,774 
,834 
4,903 
4,910 
4,919 
3,043 

Sngland  . .  % 

Russia  ....  'Z 

"       ....-£. 

[taly  

Poland....  3f 
Russia  ....  2 

Austria  ...  3^ 

VIII.  4          3 
IV.  5               1 
II.  4               1 
VUI.  4     6 

X.3i             1 
IV.  3J   1 
II.  3J    1 
IV.  5     1 

1               3     "    ... 

3     "    ... 
1 

18boui-s. 
1               Iday.... 
1             2  weeks . 
1               3       "      . 

1 
1 

1 

1 
1 

1               1 
1                 1 

Fewmin. 

1 
1                        1 

1 
1                        1 
1                        1 

1 

At  once. 

100.5 

100.5 

101.3 

102 

2d    " 

3  days . . . 

1 

D'll  1 

r 

11 

6 
6 

f 

7 

Fair.:: 

Good . . 
Impr.  . 

Fever ;  sepsis. 

Hjemorrliage ;  ancBmia 

Woman  s(rtrui7!ff ;  fcetiis  membranes  removed  intact  will 
dressing  forceps. 

Constip.;  hysteria;  lochia  serous,  mod,;  slight  odor. 
No  subsequent  fever  ;  out  of  bed  3d  day. 

lOT 

5,044 

Russia  .... 

4 

1               6  hours.. 

1                        1 

103 

103 

100.4 

103 

L.    " 

Few  hrs. 

1 

D'll  1 

i 

Good.. 

Fever;  sepsis 

108 

5,051 

"        ■■■    ? 

IV.  5 

1             3days... 

1                        1 

102.6 

1st  " 

"    1 

5 

Fever;  unknown  cause 

No  fever  after  1st  day. 

109 

5.153 

III.  5 

1              3     ■'    ... 

1                        1 

4 

110 

5,219 
5.343 

'*        .'.'.'.  2 

1.4               1 

1                        1 

100.6 

100.6 

100.6 

100.6 

1st  " 

1 

7 

Fever ;  sepsis 

Patient  discharged  in  apparently  good  condition:  2  week- 
later  again  seen,  treated,  finally  sent  to  hospital ;  piim- 

111 

ni.41 

1              1  day ... . 

M  em. 

1                             1 

4 

113 

3,380 

!!!".  2 

m.  6      1 

1 

1                       1 

1 

1 

S 

113 

5.29S 

iouraaaia.  2i 

VII.  6               1 

1 

1 

b 

1U5.318 

Russia  .... 

III.  6J             1 

4  weeks  . 

1                       1 

1 

1 

Lacerated  cervi.x. 

11515.339 

'•       ....3( 

II.  5          1 

1           1 

8 

1                   1 

f 

11615,338 

"       ....3 

VIII.  4          1    1 

1 

1 

117  3,389 

....3 

VII.  3          1 

1 

1 

1    1 

3 

U8  5.483 

....2 

1.5 

1 

1 

1 

6 

119  5.478 

I.3t 

1           1  4  days . . . 

1 

1                        1 

1 

I 

1 

130  5.575 

4          1 

11          4     "    ... 

1 

1                        1 

1 

[one  foetus  muuiinifiecl. 

131  5,6.33 

'.'.'.'.  2> 

5        V.  5             1 

1 

1      30  rain... 

1    1                        1 

101 

3d   " 

1 

1 

1 

1  2  days. 

( 

Caked  breasts;  fever 

No  fever,  excepting  3d  day  ;  sinfrle  rise  in  temp.;  twins  ; 

132  .5,647 

i    in.  6 

13     "    ... 

1      1 

1                        1 

101.4 

L.    " 

D's.  1 

6 

Fever;  sepsts 

No  subsequent  fever. 

13313.636 
134  .5.637 

'.'.■.■.  2 

J    ni.  4       3 

5        II.  4           1 

1  1          Iday.... 

1 

1                        1 
1                        1 

5  days . . . 

N.  R. 

103.4 

103.4 

L.    " 

"    1 

3      " 

6 
5 

Fever ;  sepsis 

115 

3.660 

U.  S 3 

1         1. 0          3 

1  1          3  days... 

1                         1 

1 

li      " 

126 

5.683 

II.  4               1 

1          3    ■•    ... 

1 

1                        1 

1 

5      " 

1] 

Fretus  by  volseUum  forceps. 

137 
128 

3.737 
3,769 

Russia 2 

5         1. 4               1 
0 

1         3    "    ... 
1       1 

1 

1                        1 

1 

5      " 

J 

Foetus  by  dressing  forceps. 

129 

3.793 

Germany..  2 

4              4               1 

1          12  houi-a. 

1 

1 

1                        1 

101.2 

101.3 

100.8 

100.8 

1st  " 

1  day .... 

^ 

1 

5      " 

( 

Fever  ;  sepsis 

lst&2d  stage  together;  susp.crim.abortion;  nosubseq.fever. 

130 

5,880 

Russia  —  ; 

0      VI.  4 

3  days . . . 

1 

1                        1 

At  once. 

1 

3      " 

10 

Umbihcalliernia  in  patient. 

131 

5.927 

....3 

6      IV.  5 

3     '■    ... 

1 

1 

1                             1 

7  hrs. 

10 

132 

0.098 

Austria  ...  2 

9      IV.  6j             1 

1 

124  in. 

5     "            1 

1                             1 

15    "    

10 

"    ;* 

133 

6.112 

U.S 3 

3      VI.  6          4    1 

I 

1 

1                    1 

At  onee . . . 

1 

4      " 

16 

Adherent  membranes. 

134 

6,371 

Germany..  ; 

6      IX.  5     3 

1 

1                          1 

At  once. 

] 

1 

133 

6,383 

Russia  —  ;: 

5      IV.  0               1 

1      3  weeks  . 

1 

1 

1      33niin 1 

1  day  . .  - 

101.5 

101.5 

101.5 

1    " 

D'll  1 

4      " 

( 

"    [\ 

Sepsis;  prolapsed  cord;  fever 

No  subsequent  fever.                          fno  fever  after  1st  day. 

136 

6.362 

0         1. 5i             1 

1 

91  ■' 

U  " 

5min....        1 

3  hrs.  10  m. 

101 

103 

L.    " 

1    "    '.'.'.. 

8 

Unknown  cause ;  fever 

Cause  of  fever  not  known;  child  lived  about  5  minutes; 

137 

6.674 

2      n.  3            1 

1 

1 

1    1  Ihr.aOm..    1 

1 

11 

Lochia  scant ;  serosang. 

138 
139 

6.702 
6.743 

.'.'.'.I 

4     III.  6i             1 
0      IX.  6     1        1 

1 

1 

3    ■' 

3t    "             1 
1 

1                           1 

1                           ] 

35min 

Refused  treatment  on  4th  day. 

140 

6.863 

....3 

0        V.  6          1 

1 

141 

6,909 

Germany.. 

9       11.4 

1 

.                         , 

. 

, 

3     " 

i 

Cultures  refused. 

^ 

6.915 
7,034 
7,073 
7,098 
7,107 
7,199 
7,360 

r,408 
7,405 
7.571 

Russia  ... 

IV.  4               1 

13  hours. 

1                        1 

Ohi-s 

101 

99.6 

Few  hrs. 

] 

I 

1 

5      " 

10 

Fever;  sepsis 

Woman  aniemic ;  complaining  of  pains  in  back,  etc. 

1+ 

4     III.  4          3   ] 
J  VIII.  0               1 

1  week  . . 

1 

1 

1 

1 

6    "    

1 

4      " 

11 
10 

Scrapings  for  examinations. 
Record  of  child  missing. 

1 

1 

1 

1 

1 

5 

Placenta  prfevia  suspected  in  pregnancy;  not  verified. 

141: 
14- 

148 

0      VI.  4 
.  VIII.  5 
10      VI.  61             1 

7      IV.  .51 

1             3  weeks  .    1 

1      1 

1                           1 

1 

1 

1 

4      " 

16 

Uterus  retroflexed 

Temp.  100  on  Ist,  2d.  10th,  and  12th  days. 

1 

1 

1           1 

13    " 
0    " 

a    ■•           1 

Ooz. 

1                       1 
Fewmin.       I 

1                       1 

20    "    

1 

1  hr 

103.4 

nth" 

8  days . . 

1 

1 

8 
11 

6 

Bad . : : 

Good.. 

Fever ;  caked  breasts 

Fcetus  found  in  unruptured.                                            . 
Child  took  only  one  breath;  lochia  never  offensive;  private 

physician  called  in :  late  sepsis. 
Ether  ;  degen.  of  membr.  &  plac;  removal  of  pieces  of 

membrane  with  curette ;  out  of  bed  5th  day. 

149 
15 
15 

Postpartum  hieraorrhage 

3i        4 
«  VIII.  4 

1 

1 

1 

1                          1 

3hrs  ... 
19    •'.... 

1 

1 

1 

4      " 

15 

7M- 

3      IV.  41    1    4 

1 

1 

, 

1                           1 

1 

1 

J 

15 
1.5) 
13 

T,679 
7,68i 
7,683 

U.S.  ...'.'.'. 
Russia 

»        V.3J 
•7      in.  .31 
.8      III.  4 

4  days... 

1 

1                          1 

6    •'.... 

101.3 

101.2 

101.3 

102.8 

2d    " 

14     "    .. 

1 
1 

1 

H^ 

Bad .:: 

Good . . 

Fewer;  sepsis;  pericarditis.. 

Sent  to  St.  Francis'  Hospital. 

1.5f 

7,75 

Poland  '.'.'.. 

1              3 

1                          1 

1  day .... 

1 

1 

1 

15 

7,90 

Russia  

^      III.  01 

1 

13    " 

3  lbs.            1 

'25    "    ....    ' 

^ 

^ 

IS 

Fair . '. '. 

Endocarditis 

Incubator  child;  child  disch.  living;  died  later,  hydroccpb.; 

15 

a.or 

37      XI  5     11 

^ 

double  mitral;  ascites;  hepatic  congestion. 

15 
M 

le 

8,03 
8,16 
8.34 
-8,40 

Rouraania. 
Russia 

U.S. ..;;; 

36      IX.  4i   2 
M      VI.  5 
33      IV.  4     8 
23  Vin.  5          3 

1             Sev.  wks. 
1              4  hours. . 
1 
1 

101" 

It  "           1 

1 

1                       1 

1 

1      Notobs....    1 
1 
1                      1 
1      30min.  .. 

Immed.. 

101.2 

8th" 

Few  hrs. 

1 
1 

1 

1 
1 

1 
1 
1 

2  days. 
1  day . . 

10 

10 

i 

IC 

Good : : 

Fair . ! : 

Fever ;  constipation 

Head  caught  in  os;    convul- 

Mo furtlier  record. 

Manual  extraction  of  clots  from  uterus. 

16 

8.-33 

" 

sions  7th  and  10th  day. 

n 

27      IV  5 

1                      Ret. 

lined                      1 

Curettage  refused :  discharged. 

5  8^74 

[reland!!! 

28        II"  5 

1 

1      3  hrs.  5  m..    1 

1 

1 

9 

Good . . 

Manual  removal  of  placenta  and  membrane. 

1( 

Russia  . 

29        V  4 

1   1 

1 

1 

8 

Manual  e-vtraction  of  foetus,  placenta,  and  membrane. 

1( 

16 
If 

1 
1 

-8;61 

8  8,87 

9  8,93 
0  9.11 
19.38 
2  9.43 

3  U.  S 

3     "      

0  Russia  

[     ;;      .... 

34      IX:  4          4 
10         1.5 

i    \.l    * 

31      ?      6     4 
40      VI.  5 

1 
1 
1        1 
1        1 

1 
1 

Twins . 

1 

37  grms. 

1233    "      1 
1310    "      f 

1 

1   1                   1 
1                       1 
1                       1 
I                       1 

1                            1 

1 

5  days . . . 

101 

4th  " 

3  days . . . 

1 

1 

1 

1 

1 
1 

1 
1 

1    "    .. 
3  days. 

9 
10 
S 
4 

g 

Fever;  sepsis. 

Macerated  child 

Uterine  douche  prevented  by  contracted  os. 

Breech  piesentation ;  monsti'osity. 
Slight  digital  dilatation. 

Head  caught  In  os 

1 

f»f 

3  Ireland".!'. 

29  IV.  4 

30  III.  .ii 

1 

1 

1 

10    " 

1  lb.  13  oz. 

1 

1                      1 

SOmln 

1 

1 

1 

1 

2     " 

5 

6 

Good.. 

Alcoholic;  discharged. 

1 

59,T. 

-.Russia  .... 

28       II.  4 

1                 12  houra. 

1 

30    ••    

101 

5th  " 

Few  hrs. 

5 

Fever;  constipation. 

1         1 

1    1 

1 

_ 

1 

Hidwife  called  in;  discharged. 

:  No  record ;  L.  d.  =  Labor  day. 


■O3tp.'luciaor;  Jev 


...  iL  -on.    rtccoMHio  on.no 


SPONTANEOnS   PREMATOTtE   1 


Up;  loclilQsllKht;  serous. 


THE    PREMATURE    INTERRUPTTON    OF    PREGNANCY. 


131 


Pelativk  Frequency. 

For  many  reasons  exact  figures  as  to  the  relative  frequency  of  prema- 
turel}^  interrupted  pregnancies  are  difficult  to  obtain.  During  the  first 
eight  weeks  undoubtedly  many  interruptions  of  pregnancy  pass  unnoticed, 
and  later  in  pregnancies  very  few  enter  maternities,  and  many  even  do  not 
come  under  the  notice  of  private  ^^hysicians  or  polyclinic  hospital  services. 
In  favor  of  a  greater  accuracy  of  our  statistics  is  the  fact  that  all  of  tlie 
635  cases  of  untimely  interruptions  of  pregnancy  were  outdoor  or  polyclinic 
cases,  and  patients  under  such  circumstances — in  their  own  homes — are 
more  likelj^  to  seek  aid  under  their  OAvn  roof  than  apply  for  admission  to  a 
general  or  maternity  hospital.  Therefore,  while  it  is  impossible,  with  the 
material  at  our  command,  or,  in  fact,  with  any  material,  to  indicate  in  a 
precise  way  the  frequency  of  interrupted  pregnancy,  and  at  what  period 
this  accident  is  most  prone  to  occur,  still,  for  reasons  already  given,  we 
believe  in  a  general  way  our  statistics  and  findings  are  valuable  and  in- 
teresting. 

Among  the  10,000  cases  of  labor  studied  in  this  Report,  we  find  635 
premature  interruptions  of  pregnancy;  namely,  417  abortions  and  218 
premature  labors.     This  gives  us  a  relative  frequency  of: 

One  abortion  to  every  24  labors. 

One  premature  labor  to  every  45.8  labors. 

One  premature  interruption  of  pregnancy  to  every  15.7  labors. 
The  635  cases  of  the  premature  interruption  of  pregnane}^  studied  in  this 
article   may  be   divided  and  classified  according  to  the  nativity  of  the 
patients,  as  in  the  following  table: 

Table  or  I^ativity. 


Nativity. 

Early 
Abor- 
tions. 

Late 
Abor- 
tions. 

Pre- 
mature 
Labors. 

Total 
Inter- 
rupted 
Preg- 
nancies. 

Full 

Term 

Labors. 

Total 
Inter- 
rupted 
and 
Full 
Term. 

Per- 
centage 
of  Inter- 
rupted 
Preg- 
nancies. 

United  States . . 

Germany 

Russia 

Poland 

Ireland  

England  

Austria 

Roumania 

Hungary 

Scotland 

23 

14 

160 

5 
11 

4 
10 

3 

19 

5 

117 

3 

4 

2 
5 
6 
1 

27 
15 
128 
4 
7 
3 
7 
8 
2 

69 
34 

405 
12 

22 

9 

22 

16 

6 

819 

378 
6,282 
244 
311 
112 
707 

lis 

168 

10 

3 

6 

888 

412 

6,687 

256 

333 

121 

729 

134 

174 

10 

4 

9 

7.77^ 
8.25^ 
6.08^ 
4.70^ 
6.63^ 
7.43^ 
3 .  OU 
11.94^ 
3.44^ 

Holland 

1 
3 

1 
3 

25 . 00^ 
33.00^ 

Switzerland  .  .  . 

13-2  REl'ORT   OF   THE   SOCIETY    OF   TlIK    LVlNeMX    HOSPITAL. 

Table  of  Xativiiy. — (Continued.) 


Nativity. 

Earlv 
Abor- 
tions. 

Late 
Abor- 
tions. 

Pre- 
mature 
Labors. 

Total 
Inter- 
rupted 
Preg- 
nancies. 

Full 
Term 
Labors. 

Total 
Inter- 
rupted 
and 
Full 
Term. 

Per- 
centage 
of  Inter- 
rupted 
Preg- 
nancies. 

Sweden       .    ... 

5 
4 
3 
1 
2 
20 
1 
1 
1 
1 
166 

5 
4 
3 

1 

2 

23 
1 
1 
1 
1 
199 

Canada     .    . . i 

r  ranee 

AVales               .  . 

Turkev         .... 

t 

Italy." 

Iv'V])t 

1 

1 

1 

3 

13.04^ 

Vrabia              .     

Permuda    . 

Australia    

Unknown  

•» 

12 

12 

33 

16.58$^ 

Total 

242 

175 

218 

635 

9,365 

10,000 

Again,  the  635  cases  of  the  untimely  interruption  of  pregnancy  analyzed 
in  this  article  may  be  divided  and  classified  according  to  the  age  of  the 
women,  as  in  the  accompanying  table.  For  purposes  of  comparison  here, 
as  in  the  Table  of  Nativity,  we  have  added  the  numbers  of  the  full-term 
labors  occurring  in  the  service  of  the  Hospital  during  the  same  period. 

Table  of  Age  of  Patients, 


Early 
Abor- 
tions. 

Late 
Abor- 
tions. 

Pre- 
mature 
Labors. 

Total 
Inter- 
rupted 
Preg- 
nancies. 

Full 
Term. 

Total 
Inter- 
rupted 
and 
Full 
Term. 

Per- 
centage 
of  Inter- 
rupted 
Preg- 
nancies. 

19  and  under. .. 

20-24    

25-29    

30-34    

35-39    

4(»-44    

45-49    

8 
54 
72 
47 
34 
11 

7 
42 
52 
32 
25 

4 

17 
86 
57 
26 
23 
3 

32 
182 
181 
105 

82 
18 

905 

3,455 

2,821 

1,328 

670 

77 

11 

1 

97 

937 

3,627 

3,002 

1,433 

782 

95 

11 

1 

112 

3.42,^ 
5.01^ 
6.02^ 
7.33^ 
10. 4S^^ 
18.94,^^ 

50-54    

Unknown 

16 

13 

6 

35 

31 . 25^ 

Tot;.l 

242 

175 

218 

635 

9,365 

10,000 

THE   PREMATURE    INTERRUPTION    OF    PREGNANCY. 


133 


In  the  foregoing  table  we  have,  in  addition,  worked  out  tlie  percentages 
of  the  frequency  of  interrupted  pregnancy  in  the  different  five-year  groups 
of  ages. 

Our  table  shows  a  progressive  increase  in  the  percentages  of  the  fre- 
quenc}^  of  the  untimely  interruption  of  pregnane}^  from  the  group  aged 
nineteen  years  and  under,  until  the  maximum  is  reached  between  the  fortieth 
and  fortv-fourtli  years.  It  will  be  noticed  that  there  is  little  variation  in 
the  percentages  of  interruption  from  the  twentieth  to  the  thirtieth  year, 
that  there  is  a  marked  increase  for  the  period  between  the  thirty-fifth  and 
thirty-ninth  year,  and  a  still  more  marked  increase  for  the  period  between 
the  fortieth  and  forty-fourth  year,  which  latter  period  gives  us  the  maxi- 
mum of  interruption  for  our  cases. 

From  our  studies  we  may  safely  draw  the  conclusion  that  the  least 
probability  of  an  untimely  interruption  of  pregnancy  is  before  the  twenty- 
fifth  year,  and  that  the  greatest  probability  is  after  the  fortieth  year. 

In  the  following  table  we  have  arranged  the  relative  frequency  of  in- 
terrupted pregnancy  according  to  the  number  of  preceding  labors  ( —  para), 
and  in  this  table,  too,  for  purposes  of  comparison,  we  have  added  the  num- 
ber of  mature  labors. 

Table  of  Para. 


Para. 

Early 
Abor- 
tions. 

Late 
Abor- 
tions. 

Pre- 
mature 
Labors. 

Total 
Inter- 
rupted 
Preg- 
nancies. 

Full 
Term. 

Total 
Inter- 
rupted 
and 
Full 
Term. 

I 

29 
31 
32 

29 
28 
16 
18 
15 
8 
10 

2 

22 

24 

26 

29 

15 

12 

9 

15 

6 

3 

3 

i' 

71 
31 

29 

19 

18 

11 

11 

8 

4 

5 

1 

1 

4 

122 

86 

87 

77 

61 

39 

38 

38 

18 

18 

8 

3 

5 

3 

1 

2 

2,009 

1,784 

1,438 

1,120 

860 

661 

485 

343 

227 

148 

66 

65 

33 

13 

7 

2,131 

II 

Ill 

1,870 
1,525 

TV 

1,197 

Y 

921 

YI 

700 

YII 

523 

YIII 

381 

IX , 

X 

245 
166 

XI 

74 

XII 

XIII 

68 
38 

XIY 

3 
1 
1 

16 

XY 

8 

XYI 

1 

XYII    .           ... 

1 

1 

XYIII 

XIX 

XX 

1 
Itt 

1 

28 

105 

1 

Unknown 

10 

4 

135 

Total 

242 

175 

218 

635 

9,365 

10,000 

134 


HEPOHT   OF   THE   SOCIETY    OF   THE    LYIN(i-IN    HOSPITAL, 


If,  for  purposes  of  convenience,  we  condense  the  })receding  table  of  para, 
and  recognize  three  groujis  only,  according  to  the  number  of  preceding 
laboi*s.  namely,  ]n*imi]xira\  ])luriparn?*  and  multipara^  {i.e.,  more  than  Y. 
paiw),  and  construct  a  tal)le  on  this  basis,  we  will  have  the  following: 

Table  of  Para.  —  (Condensed.) 


Para. 


Primii)ara3  . 

Pluripara^  '- 
Multipara^  , 
Unknown  . . 

Total. 


Early 

Late 

Abor- 

Abor- 

tions. 

tions. 

29 

22 

120 

94 

TO 

49 

14 

10 

242 

175 

Pre- 
mature 
Labors. 


71 

97 

4(3 

4 


Total 
Inter- 
ruj^ted 
Preg- 
nancies. 


122 
311 
174 

28 


218 


635 


Total 

Full 

Term. 


2,009 

5,202 

2,047 

107 


9,365 


Total 
Inter- 
rupted 
and 
Full 
Tenn. 


2,131 

5,513 

2,221 

135 


10,000 


(Jur  foregoing  table  shows  tliat  in  primigravidse  gestation  is  least  en- 
dangered in  the  first  months  of  pregnancy;  for  among  122  untimelj^  in- 
terruptions in  ]irimigravidae  we  find  29  early  abortions,  22  late  abortions, 
and  71  premature  labors.  Thus  we  see  again  from  the  above  that  the  fre- 
quency of  interruption  increased  with  the  further  advance  of  pregnancy. 

A  glance  at  our  table  Avill  show  that  in  ])lui'i]mra^  and  multipara^  tlie 
relation  is  reversed;  the  majority  of  interruptions  among  these  occurring 
in  tlie  first  montlis  of  pregnane}',  and  that  the  frequency  of  interruption 
now  decreases  with  the  furtlier  advance  of  gestation. 

The  greater  frequency  of  uterine  disease  in  multipara^,  and  the  large 
number  of  preceding  labors,  some  of  them,  at  least,  undoubtedly  anomalous, 
is  a  sufficient  explanation  of  the  greater  fre(|uency  of  abortion  than  of 
])remature  la1>or  in  multipara'. 

Tlie  study  of  our  material  also  allows  us  to  coniirm  the  ol)servations  of 
Winckel,'-^  Stunq)f.'  and  others,  that  with  every  additional  interruption  of 
j)regnancy  tlie  tiiiu^  of  gestation  recedes,  so  tliat  aftei'  the  occurrence  of  a 
j)remature  lahoi-  tliei-e  ensue,  first,  late  abortions,  and  iinally  early  aboi'tions. 
The  uterus,  tJKjrefore,  in  the  jireseiice  of  iiteiiiie  disease,  becomes  ever  less 
tolerant  of  siibseciuent  ])i-egnaiicies,  and  expels  its  eoiiteiits  earlier,  in  pro])0)'- 
tion  to  the  number  of  preceding  inten'upti<jns  of  picgnancy.  As  Winckel 
and  Stum])f  put  it:  "  The  longer  existence  of  iiteiine  disease  leads  to  ever 
earlier  intfjrniption  of  pregnancy.'" 

In  the  following  table  we  indicate  tlx-  ric(|tiency  of  the  iititimely  intei-- 
ruption  of  pregnancy  in  the  different  montlis  of  gestation: 

'  ]'liiri|.nr:.--^II.,  III.,  IV..   V.  panu. 


THE   PREMATURE    INTERRUPTION   OF    PREGNANCY, 


135 


Month  of  Gestation. 


Xumber 

Percentage 

Week. 

Month. 

of 

of  Inter- 

Cases. 

ruption. 

4 

I. 

6 

H 

10  Not  N'oted. 

8 

II. 

61 

9.61^  ) 
6.29^  V 

10 

n 

40 

232  Early  Abortions. 

12 

III. 

131 

20.63^  ) 

14 

31 

21 

3.31^1 

16 

IV. 

62 

9.76^ 

18 

4i 

9 

1.42^ 

20 

V. 

35 

5.51^  ^ 

175  Late  Abortions. 

22 

5i 

9 

1.42^ 

24 

VI. 

28 

4.42^ 

26 

6i 

11 

1.73^^ 

28 

VII. 

47 

7.40^1 

30 

n 

14 

2.20^ 

32 
34 

VIII. 

8i 

65 
15 

10.26^ 

2.37^  ' 

218  Premature  Labors. 

36 

IX. 

50 

7.99^ 

38 

H 

27 

4.26^^ 
Total... 

635  interrupted  Pregnancies. 

In  the  foregoing  table  the  month  of  gestation  is  not  noted  in  ten  cases 
only  (early  abortions). 

Our  material  and  the  above  table  accentuate  the  well-known  liability 
to  the  occurrence  of  interruptions  at  the  third  month  (23,91  per  cent.). 

Further,  it  is  of  interest  to  note  the  slight  liability  at  the  sixth  month 
(6.15  per  cent.);  and  also,  but  with  a  slight  increase,  at  the  seventh  month 
(9.6  per  cent.);  while  it  will  be  noted  that  in  the  eighth  and  ninth  months 
the  frequency  again  rises  (12.63  per  cent,  and  12.25  per  cent,  respectively). 


Pathology. 

The  patholog}'"  of  interrupted  pregnancy,  like  the  bacteriology,  differs 
little  or  not  at  all  from  the  disease  processes  taking  place  at  full  term. 
The  same  degenerations  (syphilitic,  hj^datidiform,  fatty,  sarcoid)  and  the 
same  infections  (septicaemic,  pyaemic,  saprsemic,  and  tuberculous)  are  found. 
It  is  difficult  to  assign  any  relative  value  to  these  morbid  conditions  in  this 
connection,  but  in  view  of  the  greater  frequency  of  sepsis  in  childbed  we 
shall  consider  that  portion  of  the  subject  first. 


136  REPORT   OF   THE   SOCIETY    OF   THE    LVlNtMN    HOSriTAL. 

The  identity  of  soptio  infections  in  all  parts  of  the  body,  though  pre- 
senting the  most  varied  clinical  ynctures,  has  been  lirndy  established  by  the 
demonstration  of  the  ))art  played  in  them  etit)loiiieally  by  ])athogenic 
miero-organisms.  The  changing  degree  in  these  processes,  nowhere  moi'e 
marked  tl»an  in  tlie  puerperium,  patent  to  all  observers,  is  explained  by  the 
theory  of  a  variation  in  virulence  of  the  microbes.  It  is  not  necessary  to 
review  the  classifications  adopted  b}'  various  authors  before  the  advent  of 
bacteriological  science;  we  merely  refer  to  the  pa})ers  of  Chailly/  Maun- 
sell,^  and  Churchill*'  as  exam})les  of  the  work  done  in  this  line  during  the 
earlier  part  of  the  present  century.  The  best  work  of  the  bacteriologists 
is  of  very  recent  date.  Haushalter,^  in  1890,  declared  that  the  strepto- 
coccus pyogenes  is  the  active  factor  in  all  forms  of  ])uerperal  sepsis;  accord- 
ing to  his  investigations,  it  is  present  in  acute  septicaemia  without  suppura- 
tion, in  pseudo-membranous  septicaemia,  in  pyoliiBinic  septicjemia,  and  in 
erysijielas.  De  Marbaix,^  three  years  later,  proved  the  above-mentioned 
changes  in  virulent  power  of  this  same  microbe.  He  believes  that  viru- 
lence is  lessened  by  age  and  by  the  failure  of  growth  of  new  generations; 
that  it  is  increased  by  inoculation  into  rabbits;  and,  in  support  of  his  theory, 
]n'oduced  eiysipelas  in  mice  from  harmless  streptococci  of  the  buccal  cavity 
and  showed  the  change  to  innocuousness  of  the  germ  taken  from  an  endo- 
carditis. WidaP  classifies  se])tic  infections  as  (lij)htlieritic,  purulent,  and 
septica'mic — all  due  to  invasion  l)y  the  streptococcus.  Bumm's  '^'  classifica- 
tion is,  however,  the  one  most  generally  accepted,  and  arranged  in  increas- 
ing order  of  virulence  is  as  follows :  Localized  septic  metritis,  thrombotic  form 
of  ]nierperal  fever,  ordinary  lymphatic  form,  and  internal  erysipelatous  form. 
Gartner's  "  work  is  considered  unsatisfactory  by  bacteriologists  iov  the  rea- 
son that  he  claims  that  culture  methods  are  unreliable,  and  pins  his  faith  to 
stained  sections  alone  for  differentiation.     He  attempts  no  classification. 

Septic  infection  may  have  its  starting-point  in  any  solution  of  continuity 
of  the  mucous  surfaces  of  the  birth  canal.  Consequently,  many  infections 
of  a  lighter  character  begin  in  injuries  of  the  cervix  and  perineum. 
Fritsch,^  among  others,  has  particularly  emphasized  the  formei*  avenue  as 
the  route  of  invasion,  and  the  thickenings  in  the  cervical  region  in  multi- 
parae  are  too  familiar  to  gynaecologists  to  need  even  a  mention.  Pelvic 
abscess,  thickening  of  the  round  and  sacral  ligaments,  and  inHammatory 
changes  in  tliem  are  secjuehe  of  cervical  infection. 

Bumm '"  and  Giirtner"  have  made  clear  the  mode  of  invasion  of  the 
organisms  at  the  phicental  site;  the  classification  of  Jhinim  is  the  result  of 
study  of  his  microscopic  preparations.  According  to  him,  se[)tic  endo- 
metritis shows  a  superficial  layer  of  necrotic  tissue  pervaded  by  ])yogenic 
and  })utr<'factivo  germs,  A  zone  <^^)f  i'('a(^tic)n,  of  pj-otection,  consisting  of 
leucocytes,  li(;s  just  below  tliis,  including  th<!  remains  of  tlu;  incnilji'anes 
and  part  of  the  nmscular  coat,  but  containing  no  bacto-ia.  The  llironibotic 
form  is  (>n]y  a  greater  d(^V(;lo])nient,  tog(!t]iei'  with  a  gcnieral  systemic  in- 
fection through  th(.'  venous  radicles.  Buti'id  <'n(lom(!tritis  and  the  reaction 
zone  are  present,  but  there  is,  in  addition,  a  |»ui-ul('nt  ])hlebitis  and  throm- 
bosis at  the  j)hu;ental  site.      'I'lx-  tliroinlii   iiiulcrgo  piinilciitdegeneration, 


THE    PREMATURE    INTERRUPTION    OF    PREGXAXCY.  137 

and  portions  of  thorn  arc  carriod  in  the  I)loo(l  sti-eam  over  tlie  body.  In 
the  lymphatic  variety,  infection  takes  place  throngh  these  channels  and 
resnlts  in  a  general  systemic  invasion.  The  decidua3  are  necrotic  and  pre- 
sent the  appearance  called  croupous.  The  organisms  pass  from  the  endo- 
metrium into  the  open  lymphatics,  AVhich  undergo  degeneration  and  form 
pus  cavities.  The  last  two  forms  may,  of  course,  occur  together.  The  in- 
ternal erysipelatous  variet}"  shows  microscopically  necrotic  decidua  in  the 
nterus  and  an  exudate  or  false  membrane  in  the  vagina.  Microscopically, 
there  is  an  ill-defined  reaction  zone,  the  cocci  have  invaded  the  uterine 
muscle  and  the  smaller  Ivmphatics.  There  is  usually  a  septic  peritonitis 
from  extension.  TTe  do  not  understand  how  this  is  to  be  separated  in  any 
way  from  the  lymphatic  form,  nor  do  we  see  the  necessity  for  the  division. 
Gartner,"  by  his  researches,  has  confirmed  Bumm's  statements  as  to  his 
thrombotic  and  lymphatic  forms  of  septic  invasion.  He  finds  no  histo- 
logical difference  between  pyaemia  and  septicaemia,  a  result  not  unexpected 
nor  unsupported,  and  thinks  the  chemist  must  make  the  diagnosis  between 
the  two. 

AVe  have  examined  microscopically  the  scrapings  of  the  uterus  in  seven 
of  our  cases,  and  present  the  results  for  what  they  are  worth.  (Compare 
Synopsis  Tables.) 

Case  6,897. — "Well-formed  placenta  showing  amnion,  chorion  with  dis- 
tinct villi  covered  with  epithelium,  decidua  with  characteristic  large  cells. 
Normal. 

Case  6,900. — About  three  months.  Yilli  extremel}^  long  and  slender, 
cells  distinct,  vessels  distended  with  blood.     Normal. 

Cases  7,211,  7,133,  and  7,083. — Xormal,  well-formed  placenta,  showing 
amnion,  chorion,  and  decidua  with  its  spongy  and  compact  layers  well 
defined.     Normal. 

Case  7,011. — Chorionic  villi,  long  and  slightly  vascular;  decidua  cells 
distinct.     Less  than  three  months.     Normal. 

Case6,8M. — Two  s|)ecimens.  a.  Amnion  and  chorion  normal.  Spongy 
layer  of  decidua  shows  necrotic  areas  around  which  is  marked  infiltration 
of  "round  cells."  Several  small  vessels  contain  thrombi,  h.  Scrapings 
from  uterus  show  decidua  only.  Uterine  glands  present  of  about  usual 
size.  Large  cells  of  decidua  normal,  and  many  are  multinucleated.  Two 
areas  of  necrosis  larger  than  in  specimen  a.  Thrombosis  also  found  in 
small  vessels.  Clearly,  a  case  falling  in  the  thrombotic  class  in  Bmnm's 
classification. 

Attention  is  drawn  to  a  point  in  treatment  suggested  by  these  patho- 
logical findings,  which  will  be  considered  at  greater  length  farther  on ;  viz. , 
the  necessity  for  non-interference,  surgically  speaking,  with  a  septic  uterus. 
It  is  never  possible  to  decide  macroscopically  to  what  extent  microbic  inva- 
sion of  the  muscular  wall  has  taken  place;  and  curettage,  in  its  softened 
condition,  is  more  than  likely,  instead  of  removing  the  offending  material, 
to  cause  a  general  infection  by  loss  of  the  protective  zone  of  reaction,  and 
the  opening  of  venous  and  lymphatic  channels  to  the  cocci  present.  This 
point  is  emphasized  by  Williams  ^^  and  others. 


138  REPORT   OF   THE   SOCIETY    OF   THE    LYIN(MN    HOSPITAL. 

Genital  tuberculosis  may  1)0  either  a  priiiiarv  or  a  secondarv  infection. 
In  the  fii*st  case,  it  takes  place  often  through  the  vagina,  usually  by  coitus ; 
in  the  second,  it  derives  its  origin  from  a  focus  of  disease  in  the  bodv.  In 
either  case  the  tubes  are  most  often  first  attacked,  especially  during  the 
period  of  menstruation  (^Si])pell ").  It  is  the  uterus,  however,  with  ^vl]ich 
Ave  are  chiefly  concerned  here.  Williams'''  and  CuUen,"^  of  the  Johns 
IIo])kins  Hospital,  have  investigated  the  sul)ject  thoroughly.  Their  papers 
contain  a  practically  complete  bibliograpliy,  with  reports  of  their  own  cases, 
and  their  conclusions  may  be  accei)ted  as  representing  the  fullest  state  of 
our  present  knoNvledge.  Chronic  diifuse  tuberculosis  begins  usuaUy  at  the 
top  of  the  fundus.  In  the  earlier  stages  it  cannot  be  made  out  macroscopic- 
ally,  and  may  be  beyond  the  reach  of  the  curette,  hidden  in  the  cornua. 
Later  the  nodules  appear  beneath  the  surface  and  finally  ulcerate.  The 
endometrium  is  transformed  into  caseous  material,  and  if  the  cervix  is 
occluded,  the  cavity  may  fill  with  detritus,  simulating  pyometra.  After  a 
time  the  tuberculosis  includes  the  jnuscular  wall.  Histologically,  in  the 
beginning,  the  epithelium  is  intact  or  proliferated  into  papillary  ])rojections, 
the  tubercles  lying  in  the  stroma;  later,  the  glands  are  affected,  tubercles 
a]:)]iear  in  their  avails,  thev  are  obliterated,  and  their  place  is  taken  by 
tuberculous  material.  The  line  of  juncture  between  sound  and  diseased 
tissue  is  sharply  defined  l)y  a  layer  of  round-cell  infiltration.  Extension 
usually  takes  place  from  the  tuljes  to  the  uterus,  and  the  process  in  them  is 
more  advanced  tlian  in  the  latter  organ.  It  may,  however,  be  infected 
])rimarily  and  directly  from  without.  Although  no  case  of  premature  de- 
livery has,  to  our  knowledge,  l)een  reported  as  due  to  uterine  tuberculosis, 
it  is  not  dirticult,  in  view  of  the  picture  just  given  of  the  degeneration  in 
endometrium  and  muscle,  to  conceive  how  such  a  condition  may  become 
possil)le. 

Lehmann  ^  repoi'tctl  t(j  tlie  iJerlin  Medical  Society  two  cases  of  placental 
tuberculosis,  one  of  the  maternal  portion  in  a  phthisical  woman,  the  other 
of  the  foetal  ])art.  The  changes  were  very  slight  in  the  jilacenta,  but  they 
point  out  an  avenue  of  entrance  for  bacilli  into  the  infant  body,  Ilirsch- 
feld  '^  and  Schmorl  ^  found  tubercle  l)acilli  in  the  foetal  liver,  the  mother 
being  |)hthisical. 

P(;i'ha})S  the  mo.st  important  ])oint  connected  with  the  pathology  of 
al)ortion  is  the  l)elief  which  has  been  in  the  ]>ast  few  yeai's  slowly  gaining 
ground,  that  even  in  instances  of  so-called  com])]!'!!'  abortion,  with  un- 
ruptured ovum,  some  slireds  of  decidua  always  ivmain  Ijehind,  a  theory 
whicli  is  str(;Mjrthcne<l  bv  the;  fact  tliat  these  cases,  treated  exiiectanth', 
always  liave  a  nujrc;  or  less  olb-nsivc  lochia,  and  that  invohition  is  always 
retarded  (DiilirssfMi  '"j. 

As  we  have;  alrcadx'  pointed  ont.  the  Icnii  (//>(>/■/ in/i,  in  its  naiTowest 
sense,  is  confined  to  tin-  spontaneous  ••iiij)tying  of  the  ntcrns  in  tluHirst 
twelve  weeks  ol"  gestation ;  namely,  to  tlu^  ])eriod  when  th<' decidua  I'etlexa 
and  vera  have  not  been  united,  and  when  active  treatment  has  for  its  object 
not  only  the  removal  of  the  ovum  with  the  decidua  reflexa  and  ])lacental 
attiichment,  but  also  of  the  decidua  vera.     Vn{\\  recently,  the  accepted  idea 


THE    PREMATURE    INTERRUPTION    OF    PREGNANCY.  139 

has  been  thut  the  ovum  separates  from  l)ekj\v  upward  (Schroeder,'^  Spiegel- 
berg  "^),  but  the  studies  of  Diihrssen^"  and  others  (Dohrn — personal  letter  to 
Diihrssen)  ai)pear  to  prove  that  this  mechanism  is  not  tlie  usual  one,  at 
least.  On  the  commencement  of  uterine  contractions,  separation  begins  at 
the  placental  site,  followed  by  the  remainder  of  the  decidua  vera  from 
above,  downward.     Careful  investigation  of  cases  bears  out  this  statement. 

Cases  of  inevitable  abortion,  with  an  unruptured  ovum,  which  permit  of 
the  passage  of  the  finger  through  the  os,  reveal  one  of  the  two  following 
conditions  :  1.  Passing  between  the  ovum  and  uterine  wall,  the  finger 
finds  a  more  or  less  firm  attachment  at  the  fundus.  If  this  is  broken  up, 
the  ovum,  consisting  of  decidua  reflexa  and  the  rudimentary  placenta,  is  re- 
moved, leaving  the  decidua  vera,  entire  or  in  part,  behind.  Its  smooth 
surface,  lining  the  uterus  except  at  the  fundus,  where  many  fine  shreds  are 
found,  is  easily  felt  by  the  finger.  Kemoval  by  curettage  proves  this  reten- 
tion beyond  doubt.  If  separation  took  place  from  below,  upward,  the 
finger  would  pass  between  uterine  wall  and  decidua  to  the  placental  site, 
and  the  ovum  be  removed  intact.  This  does  occur  in  excej^tional  cases,  but 
as  a  rule  the  finger  feels  two  smooth  apposite  surfaces,  that  of  the  reflexa 
over  tlie  ovum  and  that  of  the  vera  on  the  uterus.  This  is  due  to  the  fact 
that  until  the  end  of  the  third  month  the  firm  attachment  of  the  vera  guides 
the  finger  within  its  cavity,  between  it  and  the  refiexa.  2.  The  ovum  in 
this  case  is  found  in  the  dilated  cervix,  attached  to  the  uterine  wall  b}^  a 
pedicle  composed  of  the  vera.  The  vera  was  detached  from  above,  down- 
ward, and  is  still  fastened  to  the  lower  segment  of  the  organ.  Attempts 
at  expression  or  detachment  result  in  tearing  this  pedicle,  and  part  of  the 
decidua  vera  remains  behind.  If  separation  occurred,  as  formerly  thought, 
from  below,  up,  the  pedicle  would  extend  to  the  placental  site,  at  which 
point  alone  the  ovum  would  be  held.  This  finally  giving  way,  the  uterine 
contents  would  be  expelled  entire,  we  should  have  a  complete  abortion,  and 
the  curette  would  not  be  needed.  It  is  because  the  first  is  the  more  frequent 
occurrence  that  retention  of  the  decidua  happens  after  spontaneous  abortion 
or  abortion  after  the  use  of  tampons,  and  hsemorrhage  and  sepsis  are  pro- 
duced. (As  Diihrssen  ^'^  and  others  have  pointed  out,  it  is  quite  possible 
that  varieties  of  placental  attachment  may  influence  the  mode  of  separation 
and  expulsion.) 

Moreover,  the  decidua  vera  may  be  expelled  even  before  the  ovum,  when 
it  becomes  detached  from  the  uterine  walls  by  blood  extravasation.  Again, 
in  old  cases  of  neglected  incomplete  abortion,  the  curette  secures  nothing 
but  a  portion  of  rudimentary  placenta,  because  the  vera  has  been  washed 
away  after  breaking  down,  as  in  labor  at  term. 

Macroscopical  examination  cannot  always  determine  that  the  ovum  is 
intact.  Exploration  of  the  uterus  alone  gives  a  positive  diagnosis.  Diihrs- 
sen^^ curetted  after  twelve  cases  of  apparently  complete  abortion,  and 
the  microscope  demonstrated  that  more  or  less  decidua  was  retained. 

Winckel  ^^  believes  that  the  entire  ovum,  intact  with  the  vera,  may  pass 
out  in  the  first  months.  AVhen  separation  does  take  place,  it  is,  in  his 
opinion,  at  the  decidua  serotina,  leaving  the  ovum  behind.     Again,  the 


140  KEPURT   OF   THE   SOCIETV    OF   THE    LVINIMN   HOSPITAL. 

ivHexa  may  be  lorii  in  the  ovuui's  tlosc-eiit,  loavinii-  it  witli  the  vera  and 
sei'otina  to  })ass  away  durinii-  the  puerpei-ium,  ov  to  be  reuioveil  by  curet- 
tage. It  is  possible  for  the  chorion  to  be  ruptured  as  well,  the  cord  being- 
torn  from  the  placenta;  and  the  embryo,  enclosed  in  amnion,  alone  expelled. 
The  mechanism  last  mentioned  is  the  rarest,  but  may  occur  even  at  the 
sixteenth  or  twentieth  week.  A  mollification  of  it  is  shown  when  decidua 
vera,  reflexa,  and  chorion  are  torn  away,  leaving  the  placenta,  fitted  like 
a  cap,  on  the  amnion. 

The  question  of  the  propriety  of  interfei-ence  must  rest  npon  clinical 
results,  iiowever,  and  not  upon  theoretical  deductions.  Clinical  experience 
shows  us  that  the  mechanism  of  placental  and  decidual  separation  varies 
according  to  the  ])eriod  of  gestation.  Klein-'  has  recentW  studied  the 
process  of  involution  of  the  decidua  after  abortion  and  labor  at  term.  lie 
reached  the  conclusion  that,  after  abortion,  the  vera  remains  wholly  or  in 
part  in  the  uterus.  The  decidual  cells  and  superficial  epithelium  ])erish 
in  loco  by  necrosis.  The  necrotic  mass  is  absorbed  or  expelled,  and  the 
epithelium  regenerated  from  l)elow.  The  ])rocess  is  terminated  in  four  to 
six  weeks.  At  term,  a  fatty  degeneration,  a  coagulation  necrosis,  occurs 
in  the  cells  of  the  decidua,  which  fomis  a  line  of  demarcation  between  the 
deep  layer  of  the  vera  remaining  in  the  uterus  and  the  upper  destructible 
layer  forming  a  physiological  separation  zone,  so  tluxt  at  labor  there  passes 
out  with  the  ovum  the  greater  part  of  the  uterine  surface  which  has  be- 
come decidua.  The  membranes  and  placenta  are  completely  expelled,  except 
when  they  are  more  intimately  attached  to  the  wall,  as  by  inflannnatory 
change  in  chronic  endometritis.  This  physiological  change  of  fatty  necro- 
sis, the  anatomical  condition  resulting  from  it,  and  the  method  of  separa- 
tion at  term,  vary  widely  from  that  found  in  abortion  explained  above,  and 
constitute  the  great  argument  in  favor  of  an  active  treatment  in  abortion 
dui'ing  the  ])eriod  before  the  sixteenth  week. 

The  sequelae  of  incomplete  abortion  furnish  further  proof  of  the  necessity 
of  oi>erative  interfei-ence.  Ekstein-'  l^elieves  endometritis  post  al)ortum  to 
be  of  common  occurrence;  and  in  two  cases  in  which  curettage  alone 
brought  the  haMuorrJjage  to  a  standstill,  the  microscope  revealed  in  the 
shreds  glandular  hy))ertro])hic  endometritis.  Kiii'stner^'  has  brought 
positive  proof  to  show  that  an  enilometritis  nui}'  depend  on  inconq)lete 
aijortion,  iOv  in  a  ])oly]nis  removed  from  a  uterus  he  found  placental 
cotyledons.  Fritsch  ■■^'  is  convinced  that  endometritis  is  es])ecially  liabh>  to 
follow  abortions.  The  decidua,  being  already  hypertrophic  and  unable  to 
involute,  undergoes  furtlier  thickening  and  remains  subject  to  hiLMUorrhage. 
Aside  from  this,  interstitial  iuManunation  and  other  inflammatory  con- 
•ditions  arise,  resulting  in  involvement  of  tin;  glands  and  jn-esenile  atrophy, 
Schroeder'^  s])eaks  of  the  inllammatoi-y  interstitial  areas,  and  states  that 
they  must  be  difFcrentiated  IVoin  so-calli'd  eiidoinetritis  post,  altdi'tiim  in 
which  the  haemorrhage  results  by  re;is(»n  of  retained  seeundines  niei'eiy. 
On  the  other  hand,  Wi  nek  el, 2'''  followiiiL:'  oiit  his  claim  that  abortion  may 
be  complete,  h(;lds  that  the  chronic  enduniet  rit  is  is  dui'  to  puerpei'al  causes, 
an  upward  extension  <•!'  ;i  eci\  ic;d   'iitnn-h.      I'oriik,"'    IVoni   ;i  study  of  ;]20 


THE    PREMATURE    INTEllRL'PTIOX   OF    PREGNANCY.  141 

cases  of  abortion  aiul  iiiiinature  lal)or,  although  recognizing  tliickoning  and 
adhesion  of  the  decidua  to  be  the  most  frequent  cause  of  the  accident,  denies 
that  the  condition  demands  curettage,  reserving  the  latter  for  hiemorrhage 
and  endometritis,  holding  at  the  same  time  that  the  membranes  are  spon- 
taneously eliminated. 

We  have  now  reached  the  last  division  in  the  subject  of  patholog}^, 
namely,  the  degenerations  of  placenta  and  decidua  concerned  in  the  pro- 
duction of  abortion  or  occurring  as  a  sequela  of  the  accident.  Of  these, 
the  syphilitic  is,  of  course,  much  the  most  important,  not  onl}'"  in  view  of 
its  frequency,  but  as  regards  the  infant  mortality,  even  in  cases  when  the 
labor  is  at  term.  According  to  Councilman, s"  little  advance  has  been 
made  in  this  line  since  the  publication  of  Frankel's  classical  work.  Briefly 
summed  up,  the  conclusions  are  these:  {a)  There  is  a  syphilitic  disease  of 
the  placenta,  found  only  with  congenital  disease  of  the  foetus,  characterized 
by  hyperplasia  of  the  epithelial  and  stroma  cells  of  the  villi,  producing 
compression,  sometimes  complete  obliteration  of  the  vessels.  The  pro- 
liferated cells  finally  undergo  fatty  degeneration.  The  vessels  themselves 
show  few  changes,  and  these  chiefly  of  an  atheromatous  nature  (Oedmans- 
son).  There  are  slighter,  focal  changes  in  the  placenta  in  syphilis,  which 
are  probabl  v  of  much  less  importance  to  the  foetus.  Macroscopically,  the 
lesions  consist  of  a  hypertrophy  of  the  entire  organ  or  some  of  its  cotyle- 
dons. (Jj)  AVhen  the  disease  is  conveyed  by  the  father,  the  mother  being- 
healthy,  the  foetus  and  placenta  are  affected.  When  the  mother  is  attacked 
with  the  embrvo  in  conception,  the  placenta  is  generally  diseased  in  both 
foetal  and  maternal  portions.  If  the  woman  becomes  syphilitic  later,  the 
placenta  may  be  sound  or  diseased ;  in  the  latter  case,  its  affection  is  gum- 
matous syphilis.  In  infection  after  the  seventh  month  there  is  usually  no 
specific  change  in  foetus  or  ])lacenta.  It  is  often  difficult  to  decide  whether 
intrauterine  death  and  abortion  are  due  to  this  disease  of  the  placenta 
alone,  since  the  lesions  in  the  child  are  often  far  more  advanced,  although 
its  injurious  effect  on  foetal  vitalit}^  must  remain  unquestioned. 

Among  the  important  causes  of  intrauterine  death  are  faulty  conditions 
of  the  foetal  envelopes  and  appendages.  These  conditions,  on  the  maternal 
side,  according  to  Priestly,^-  are  imperfect  or  excessive  development  of  the 
decidua  or  extravasation  of  blood  between  reflexa  and  chorion,  causing 
the  so-called  apoplexy  of  the  ovum.  Inflammation  of  the  decidua,  decidual 
endometritis  of  whatever  form,  is  a  prime  factor  (Virchow)  in  the  causation 
of  chorionic  disease,  the  villi  being  unable  to  take  root  in  its  indurated  and 
thickened  substance.  The  death  of  the  foetus  is  the  natural  sequence  of 
chorionic  changes  Avhich  are  chiefly  cystic,  resulting  in  the  condition  known 
as  hydatidiform  mole.  Virchow's  view,  that  the  true  nature  of  this  de- 
generation is  myxomatous,  is,  as  will  be  seen,  at  least  probably  correct. 
Hehrer  ^'  has  tabulated  fifty  cases  of  this  affection,  showing  clearly  its  rela- 
tion to  our  subject.  Abortion  occurred  at  the  fourth  month  in  fifteen 
cases,  at  the  fifth  in  thirteen;  two  only  were  delivered  at  term,  and  two 
aborted  in  the  second  month.      In  more  than  half  the  patients,  flooding 


142  KEl'OHT    OF   THK    SOCIKTV    OK    THK    LYINC-IX    HOSPITAL. 

occiirred.  In  tlnrty-four  cases  expectant  treatment  vesnlted  satisfactorily, 
l)Ut  aniono;  the  rest  were  cases  of  debility,  fever,  etc.,  a  clear  indication 
for  jM'ophylactic  curettage,  altliongh  no  deaths  resulted.  Sterility  was  by 
no  means  the  rule  in  these  cases  after  molar  ])regnancy. 

Hvdatidiform  degeneration  of  the  placenta  has  ac(]uirod  in  late  j'^ears  a 
new  interest,  aside  from  its  role  in  the  etiology  of  abortion.  This  is  found 
in  its  frequent  occurrence,  not  to  put  the  case  too  strongly,  })receding  the 
condition  appropriately  termed  "  deciduoma  malignum.'"  Of  twenty-six 
undoubted  cases  collected  by  'Williams,^  eleven  have  followed  hydatidiform 
moles.  ''When  we  consider  the  marked  infrequency  of  hydatidiform 
moles  in  general,  and  the  very  large  proportion  of  the  cases  of  deciduomata 
which  have  been  preceded  by  them,  it  is  not  difficult  to  believe  that  they 
stand  in  some  sort  of  causal  relation."  Williams  thinks  thiit  too  much 
stress  should  not  be  laid  on  this,  since  there  is  no  structural  difference  be- 
tween deciduomata  following  moles  and  ordinary  pregnancies.  Preg- 
nancy itself  seems  to  be  a  condition  sine  qua  non  for  the  tumor  develop- 
ment, foi'  of  the  remaining  fifteen  cases,  five  followed  full-term  pregnancies, 
five  followed  abortions,  one  a  tubal  pregnancy ;  in  three  the  form  was  not 
stated.  Decidnoma  maltgiium  is  a  clinical  term,  including  several  varieties 
of  tumors,  sarcomata,  carcinomata,  and  mixed  growths,  all  being  derived 
from  one  or  both  of  the  component  parts  of  normal  decidua,  connective 
tissue,  or  epithelium.  Metastases  form  in  various  parts  of  the  body  (the 
vulva,  in  "Williams's  case),  and  present  all  the  characters  of  the  original 
tumor.  In  case  the  growth  is  derived  from  the  stroma,  it  is  a  sarcoma; 
when  from  one  or  both  layers  of  decidual  epithelium,  a  carcinoma.  Menge  ^ 
has  described  a  case  in  which  both  varieties  occurred  too-ether.  llistoloo-- 
ically,  the  greater  part  of  the  tumor,  as  well  as  the  metastasis,  is  made  up 
of  blood  lying  free  in  the  tissues  or  enclosed  in  spaces  formed  l)y  the  tumor 
cells.  In  the  carcinomata,  the  cellular  portion  consists  of  ei)ithelioid  cells 
derived  from  the  Langhans  layer  of  the  decidual  epithelium  or  of  masses  of 
syncytium,  a  protoplasmic  network  without  definite  division  into  cells,  with 
dee])ly  staining  nuclei,  vacuolated,  the  vacuoles  being  empty  or  containing 
a  trans]>arent  suljstance.  This  syncytium,  cut  in  various  directions,  gives 
the  giant-cell  appearance  so  often  described,  protoplasmic  masses  filled  with 
nuclei,  in  the  ]ilacenta;  in  short,  it  is  merely  a  reproduction  of  the  outer, 
probal^ly  maternal,  layer  of  chorionic  e])itholiuni.  ^"o  traces  of  ])lood- vessels 
are  to  be  found  nnd  no  I'dicnhiin.  Tlic  cpitliclioid  colls  and  syncytial 
masses  arc  ari-an^cd  without  an  atti'inpt  at  foi'ination,  without  connection 
witii  suri'ounding  tissues.  The  sarcomata  liave  \\\o,  same  blood  si)aces,  sui"- 
rounded,  however,  by  connective-tissue  (•••lis  witli  a  well-marked  sti-oina,  no 
syncytium  being  ])resent;  tlx'  carcino-sai'coniala  ])i'esent  the;  coml)ined 
features  of  these  two  tumors.  "When  l)y  cell  proliferation  the  blood  s|)a.ces 
are  obliterated,  the  tumoi-  undergoes  central  necrosis. 

Clinically,  tJK;  growth  is  of  fi-ightful  malignity,  (h^ath  usually  occui-i-ing 
within  six  months  aft(ir  tin;  first  a|)pearancc  of  sym])toms.  It  soon  in- 
filtrates the  uterine  well,  destroying  it,  entering  th(.'  blood  stream,  and  re- 
])rodMcing  itself  in   other  ])arts.      In  view  of  the   iniilignity  of  decidnoma, 


THE    PREiMATURE    I^'TERRUPTION    OF   PREGNANCY.  143 

earlv  diagnosis  is  imperative,  and  in  cases  of  haemorrhage  late  in  the  puer- 
])erium  or  jnst  following  it,  especially  in  a  hydatidiform  ])regnancy,  curet- 
taa'e  of  the  uterine  cavitv  should  be  done  at  once.  If  traces  of  deciduoma 
malignum  are  found,  the  uterus  should  be  at  once  extirpated,  if  it  is  not 
already  too  late.  (A  complete  bibliography,  with  illustrative  histological 
plates,  will  be  found  in  Williams's ^^  article.) 

Conditions  of  the  Ovum,  Embkyo,  and  Fcetus,  and  Pkesentation  of 
THE  Fcetus,  in  oue  635  Cases  of  Untimely  Intekkuption  of  Preg- 
nancy. 

Early  Abortions. — Our  statistical  tables  shovr  that  the  ovum  in  our  242 
cases  of  early  abortion  was  expelled  unruptured  in  only  forty-two  instances, 
or  one-sixth  of  all  cases;  that  in  sixty-nine  instances  rupture  of  one  or 
more  envelopes  of  the  ovum  occurred  before  expulsion,  resulting  in  an  ex- 
pulsion in  a  more  or  less  broken-up  condition,  in  one  or  other  of  the 
mechanisms  already  pointed  out  in  foregoing  sections. 

Expulsion  or  the  Ovum  in  Eakly  Abortions. 

Cases. 

Ovum  expelled  unruptured 42 

Ovum  expelled  broken  up 69 

]^ot  noted  on  histories 131 

Total 242 

Our  tables  further  show  that  of  our  242  cases  of  earlv  abortion,  162 
were  of  the  incomplete  variety ;  namely,  the  embryo  had  escaped,  lea^n^ng 
behind  the  whole  or  a  part  of  the  secundines,  when  the  Hospital  official 
made  his  first  visit.  Further,  of  the  176  cases  in  which,  when  first  seen, 
the  embryo  had  escaped,  only  14  were  considered,  from  an  examination  of 
the  decidua,  to  be  "  complete  ' '  abortions. 

Regarding  the  nature  of  the  remaining  <6'6  cases,  when  first  visited  48 
were  inevitable,  of  12  we  have  no  record,  and  6  were  threatened,  but  sub- 
sequently, in  spite  of  treatment,  aborted. 

Character  of  the  Early  Abortions  when  First  Visited. 

Cases. 

Incomplete  abortion 162 

Inevitable  abortion 48 

Complete  abortion 14 

ISTot  noted  on  histories 12 

Threatened  abortion 6 

Total 242 

Late  Ahortions. — The  statement  found  among  most  classical  authors, 
that,  as  a  rule,  in  abortion  the  foetus  has  ceased  to  live  before  its  expulsion, 


14-1:  REPORT   OF   THE   SOCIEfV    OF   THE    LYING-IX   HOSPITAL. 

would  a})peav  to  be  strengthened  by  our  observations,  although  some  mod- 
ern writers,  notably  of  the  French  school,  contradict  this  statement. 

Condition  of  the  Fcetls  at  Time  of  .1)1kth  in  Late  Abortions. 

Cases. 

Still-born 106 

Still-born  and  macerated 19 

Lived  a  lew  minutes 0 

Lived  a  few  hours 3 

No  record  on  histories -11 


Total 1 


iO 


Spontaneous  Premature  Labor. — As  regards  the  condition  of  the  foetus 
and  the  subsequent  results  for  living  children,  we  are  at  once  impressed 
with  the  very  small  proportion  of  children  alive  at  birth  that  survived  even 
the  short  ]ieriod  of  attendance,  which  in  spontaneous  premature  delivery 
averaged  9  days  and  T  hours. 

After  the  establishment  of  a  main  Hospital  Ijuilding  in  November,  1894, 
when  possible,  cases  of  [)remature  children  were  transfei'red  to  the  Hospital 
wards  and  placed  in  the  couveuse.  By  referring  to  the  latter  portion  of 
our  statistical  table  of  premature  labor,  it  will  be  seen  that  a  number  of 
such  children  were  so  treated.  While  the  number  of  children  so  treated 
was  small,  still  the  results  seen  in  even  this  small  number  were  better  than 
those  of  the  ordinary  treatment  of  the  tenement  houses. 

Condition  of  the  Child  at  Time  of  Bikth  in  Peematuke  Labor. 

Cases. 

Still-born 47 

Still-born  and  macerated 43 

Lived  a  few  minutes 4 

Lived  some  hours 25 

Lived  some  days 53 

Living  wlien  discliarged 32 

No  recoi'd  on  histories 34 

Total 238 

Twins,  20  cases. 

In  late  abortions,  as  well  as  in  spontaneous  premature  labors,  the  great- 
est interest,  to  the  writer  at  least,  centres  about  the  I'clative  frequency  of 
the  various  pi'esentations  of  the  foetus.  We  cannot  but  believe,  as  the  re- 
sult of  an  extended  study  of  the  literature  of  the  subject,  that  this  portion 
of  the  pathology  of  llic  premature  interru]»1  ion  of  pregnancy  has  been  sadly 
neglected. 

We  find  the  repeated  classical  statemcnl  tli;U  at  lull  term  vertex  pre- 
sentations obt;i  in  in  '.».")   i)(;i- cent,  of  cases,  ;inil  tlial  the  ])ercentage  is  much 


THE  PREMATURE  INTERRUPTION  OF  PREGNANCY.  145 

less  prior  to  tlie  delivery  of  a  mature  foetus,  but  in  what  })roportioii  few 
have  attempted  to  enlighten  us. 

We  believe  the  statements  of  Matthews  Duncan  and  the  later  ones  of 
Pinard  are  not  dis])uted;  namely,  that  during  the  first  six  months  of  gesta- 
tion the  superior  segment  or  fundus  of  the  uterus  is  more  develo])ed  than  the 
inferior,  and,  likewise,  that  during  this  period  the  head  of  the  foetus  is  rela- 
tively much  larger  than  its  bod^v. 

Further,  during  the  first  two-thirds  of  pregnancy,  by  reason  of  the  liquor 
amnii,  the  foetus  enjoys  certain  liberties  and  readily  moves  about  and 
changes  its  presentation  and  position ;  but  as  the  last  third  of  gestation 
progresses,  the  general  movements  become  less  and  less,  and  the  foetus 
graduall}^  assumes  what  are  recognized  as  its  normal  attitude,  presentation, 
and  position.  Up  to  the  last  third  of  gestation  the  total  area  of  the  uterine 
cavity  far  exceeds  that  of  the  foetus,  so  that  before  this  time  and  in  the 
early  part  of  the  last  third  the  tendency  to  accommodation  is  not  absolute 
as  it  subsequently  becomes. 

Presentations  of  the  Fcetus  in  Late  Abortions. 

Cases. 

Cephalic  presentation  11 

Podalic  presentation  11 

Shoulder  presentation 0 

IS'ot  noted  on  histories 153 

Total 175 

We  observe  in  the  foregoing  table  that  of  the  22  cases  of  late  abortion 
in  which  the  presentation  Avas  noted,  this  number  is  equally  divided  between 
cephalic  and  podalic  presentations.  This  substantiates  what  we  have 
already  said  regarding  the  accommodation  or  adaptation  between  the 
superior  and  inferior  uterine  segments  and  the  relative  size  of  the  foetal 
body  and  head. 

Unfortunately,  we  have  no  records  of  the  relative  f requeue}^  of  shoulder 
presentation  to  compare  with  the  above. 

Our  table  shows,  however,  that  in  the  fourth,  fifth,  and  sixth  months  of 
gestation,  the  foetus  being  quite  movable  in  the  liquor  amnii,  the  superior 
uterine  segment  being  relatively  larger  than  the  inferior,  and  the  foetal 
head  relatively  larger  than  the  body,  the  breech  presents  with  equal  fre- 
quency as  the  vertex  (11  to  11). 

Turning  now  to  spontaneous  premature  labor  and  comparing  the  pres- 
entations here  with  those  of  late  abortions,  we  observe  a  gradual  increase 
in  the  proportion  of  vertex  presentations  and  a  lessening  of  the  proportion 
of  breech  presentations.  In  the  seventh,  eighth,  and  ninth  months  of 
pregnancy  the  adaptation  or  accommodation  of  the  cephalic  and  podalic 
extremities  of  the  foetus  to  the  corresponding  smaller  and  larger  uterine 
segments  respectively  becomes  more  constant,  and  the  foetus  gradually  takes 
up  the  physiological  posture  of  normal  vertex  presentation. 

It  will  be  observed,  moreover,  that  while  the  number  of  shoulder  pres- 

10 


146  KEPORT   OF    THE   SOCIETY    OF   THE    LYIXG-IN    HOSPITAL. 

entations  is  ooi  n  ]  )a  rati  vol  y  small  (7  in  288  presentations),  still  the  propor- 
tion is  much  greater  than  that  of  t'nll-term  delivery;  namely,  1  in  34 
presentations,  as  against  1  in  250  presentations. 

Presentations  of  the  Fcetus  in  Spontaneous  Premature  Labor. 

Cases. 

CVi)halic  (vertex)  presentation 129 

Poilalic  (breech)  jiresentation 55 

Shoulder  presentation 7 

Xot  noted  on  histories 47 

Total ~2SS 

The  above  table  includes  twenty  cases  of  twin  delivery,  and  we  append 
the  presentations  in  these  cases  separately,  in  the  following  table: 

Presentations  of   the   F(etus    in   Twenty  Cases   of   Spontaneous   Twin 

Premature  Labor. 

Cases. 

Both  twins  cephalic  presentation 6 

Both  twins  podalic  presentation 4 

One  cephalic  and  one  podalic  presentation 7 

One  cephalic  and  one  not  noted 1 

One  podalic  and  one  not  noted 1 

Xot  noted  on  histor}^ 1 

Total 20 

Although,  as  we  believe,  little,  if  any,  interest  attaches  to  the  subject, 
still  we  append  the  sex  of  child  in  our  238  children  born  in  spontaneous 
premature  delivery. 

Sex  of  Child    in  Spontaneous  Premature  Labor. 

Cases. 

Male 107 

Female 113 

Xot  noted  on  history 18 

Total 238 

We  have  endeavored,  further,  to  establisli  Irom  our  cases  of  spontane- 
ous premature  delivery  th(;  connection  and  relationship  existing  between 
the  vai'ious  jjrosontations,  according  as  tlic  fo'tus  be  dead  or  alive.  Tii  the 
total  numljcr  of  2;5s  premature  cliikh-en,  including  living,  still-lK)i-n,  twins, 
and  still-born  and  nuicerated,  there  were: 

Cases. 

Cephalic  (vertex)  presentation 121)  or    54.20^ 

Pochilic  (breech)  presentation 55  "     23.12ji^ 

Shoulder  prcsfntalion 7  "       2.95^ 

jS'ot  noted  (.ii  history 47  "     19.23^ 

Total 238 


THE    PRKMATrUE    INTERRUPTION    OF    PREGNANCY.  147 

111  the  total  number  of  238  premature  children,  including  the  twenty 

twin  cases: 

Cases. 

Foetus  was  born  living 114  or  4Y.89^ 

Foetus  was  still-born 47  "  19.75^ 

Foetus  was  still-born  and  macerated 43  "  18.07^ 

Condition  not  noted  on  histories 34  "  14.29^ 

Total 238 

In  the  114,  or  47.89  per  cent.,  cases  of  the  preceding  table  in  which  the 
foetus  was  born  alive,  we  jfind  the  following  presentations: 

Cases. 

Cephalic  (vertex)  presentation 75  or  31.50^ 

Podalic  (breech)  presentation 22  "  9.24^ 

Shoulder  presentation 2  "  0.84^ 

'Not  noted  on  histories 15  "  6.30^ 

Total 114 

In  the  47,  or  19.75  per  cent.,  cases  of  our  table  in  which  the  foetus  was 
still-born,  we  find: 

Cases. 

Cephalic  (vertex)  presentation 22  or  9.24^ 

Podalic  (breech)  presentation 14  "  5.88^ 

Shoulder  presentation 3  "  1.26^ 

I^ot  noted  on  histories 8  "  2.52^ 

Total 47 

In  the  43,  or  18.07  per  cent.,  cases  of  our  table  in  which  the  foetus  was 
both,  still-born  and  macerated,  we  find: 

Cases. 

Cephalic  (vertex)  presentation 21  or  8. 

Podalic  (breech)  presentation 15  "  6. 

Shoulder  presentation 0 

]^ot  noted  on  histories 7  "  2.94^ 

Total 43 

From  the  preceding  three  tables  we  can  construct  the  foUowdng: 

Yertex.  Breech, 

Living  children 31.50^  9.24^ 

StiU-born 9.24^  5.88^ 

Still-born  and  macerated 8.82^  6.30^ 

This  table  shows  markedly  the  predominance  of  vertex  presentations  in 
foetuses  born  alive  (31.50  percent,  vertex,  and  9.24  per  cent,  breech,  in 
living  foetuses) ;  moreover,  the  sharp  decline  in  the  excess  of  vertex  presen- 
tations over  breech  when  a  still-born  or  still-born  and  macerated  foetus 
obtains  (9,24  per  cent,  vertex  and  5.88  per  cent,  breech  in  the  former,  and 
8.82  per  cent,  vertex  and  6.30  per  cent,  breech  in  the  latter). 


148  REPORT   OF   THE    SOCIETY    OF   THE    LVIXlMN    HOSPITAL. 

It  would  1)0  of  interest  at  this  point  to  stiulv  the  iulluence  of  tlic  cause 
of  tlie  premature  deliverv  ui)on  the  vitality  and  condition  of  the  product 
of  conception  at  the  tinu^  of  bivth.  Foi-  exaini)le,  what  proportion  of  tlie 
chiklren  were  born  living,  still-born,  and  still-born  and  macerated  in 
instances  in  which  the  cause  of  the  interru])ted  ])reg-nancy  was  known  to 
be  faulty  im])]antation  of  the  placcMita  (piun'ia),  syphilis,  and  albuminuria 
(toxa^m i a )  res | >ec t  i vely 

l)rit)n  **^-'  found  that  in  vicious  insertion  of  the  ])lacenta  the  fo3tus  was 
born  most  fre(|U('ntly  alive;  in  syphilis,  almost  always  still-born  and 
macerated;  and  in  albuminuria  (toxaemia),  the  living  and  still-born  children 
were  of  about  equal  ])roportion. 

Study  and  investigation  in  this  direction  ^vould  doubtless  aid  us  in  the 
])reventive  treatment  of  subsecpient  interi'U})tions  of  pregnancy  in  those 
instances  in  which  only  a  suspicion  of  the  real  cause  of  the  accident  can  be 
obtained  from  the  clinical  history  of  a  patient.  Although  our  histories  do 
not  i^ermit  us  in  any  l)ut  a  small  ])roportion  of  our  cases  to  state  the  cause 
of  the  accident  (see  Etiology),  still  the  above  reference  to  the  relationship 
between  the  etiology  and  the  condition  of  the  child  at  birth  is  introduced 
here  in  order  that  in  future  re]K)rts  upon  untimely  interrupted  pregnancies 
the  matter  may  be  given  due  attention. 

Bacteriology. 

This  division  of  the  subject  is  introduced  in  the  hope  of  forging  an 
additional  link  in  the  chain  of  argument  in  favor  of  the  active  procedure 
adopted  in  most  of  our  cases,  as  well  as  to  place  on  record  the  results  of 
certain  Imcteriological  investigations  which,  to  our  knowledge,  have  not 
])reviously  Ijeen  made  in  pi'cmaturely  interrupted  deliveries  both  before  and 
after  operation  and  at  tlie  end  of  the  puerperium.  Puerperal  infection 
is  the  same  here,  of  course,  as  in  full-term  labors,  sapra^mia  or  septictrmia 
and  pya-mia  resulting  from  the  invasion  of  sapro])li3^tic  or  j)athogenic  organ- 
isms in  an  identical  fashion.  Puerperal  sapr^emia,  a  term  iirst  used  by 
^[atthews  Duncan,^  signifies  a  poisoning  of  the  organism  fi-om  ])tomaines 
resulting  f)-oin  ])Utrefaction  processes  in  the  l)irth  caiud.  Its  a<lvocates 
describe  a  com})lete  symptom-complex  f<j7'  it.  The  saprophytes  effect  an 
entrance  usnally  dui-inga  prolonged  and  dilhcult  labor,  and  A  hi  fold  •'"makes 
the  statement  that  in  well-conducted  maternities  the  cases  of  fever  from 
auto-infection  and  sapraemia  outnumber  those  in  which  there  is  a  direct 
contagion.  Lately,  this  extreme  view  has  been  attacked.  Pumm,-'"  in  1SJ)1, 
discovered  streptococci  in  eight  of  eleven  cases  with  a  clinical  history  of 
putrid  endonu^tritis,  and  von  Franque,^  in  a  typical  case  of  sapraemia, 
found  f)n]y  a  ])ure  cidturc  of  strc])tococci.  lie  iind  Williams"'"  regard  the 
condition  :is  i"ire  in  tlu;  puerp(?rium. 

No  such  uncertainty  attaches  to  infectifni  \>y  pyogenic  organisms.  From 
the  time  of  the  app(!arance  in  18<ll  of  Semmehveiss's''"  paper,  opening  the 
(juestion,  the  doctrine;  of  infection  in  puerperal  septicaemia  has  gained 
ground;  and.  thanks  to  the  labors  of  numerous  inv(;stigators(  May  rhofer'"'  in 
1865,  then    Kin.Kleisch,''^  Recklinghausen,--'    Waldeyer,**    Klebs,«    Orth,5« 


THE    PREMATURE    INTERRUPTION   OF    PREGNANCY.  149 

Rpillman/"  and  otliers),  the  streptococcus  was  early  recognized  here,  as  in 
otlier  wounds,  as  the  chief  offender.  Pasteur/^  in  1880,  first  cultivated  it 
from  the  uterus  of  a  woman  dead  of  childbed  fever.  He  was  followed 
by  many  men  (Friinckel,'"'^  AVinckel,^"  Bumm,'"'  Doderlein,^*'  Winter,*'^  etc.) 
whose  names  are  a  guarantee  of  their  Avork.  Brieger,^^  Czerniewsky,"^ 
Fehling,^^  Hagler,^''  and  Doderlein'^  have  reported  cases  in  which  the 
staphylococci  were  brought  forward  as  the  cause  of  mikler  cases  of  puer- 
peral septicaemia,  following  out  their  role  in  other  wound  infections,  their 
virulence  being  less  than  that  of  streptococci.  Doderlein^^  has  recorded 
an  epidemic  in  Leipzig  in  which  the  two  were  found  together.  These,  how- 
ever, are  not  the  only  pyogenic  microbes  concerned  in  the  causation  of 
puerperal  fever.  Konig  *^  has  made  a  pure  culture  of  gonococci  from  the 
uterus  in  nine  cases ;  von  Franque  ^  found  the  bacillus  coli  communis  in 
pure  culture  in  the  uterus  once;  the  bacillus  proteus  has  been  cultivated 
from  ovarian  abscess  and  fatal  peritonitis  (Flexner^)  caused  by  it,  and 
it  seems  probable  that  it  will  be  found  in  cases  of  septicaemia,  as  Kuliscioff  ^^ 
surmised.  Hej^se"*^  has  recorded  a  case  of  puerperal  tetanus  in  which  the 
bacilli  were  found  in  the  woman's  cervix  and  the  dust  of  her  room. 

Having  established  the  fact  that  these  organisms  may  be  concerned  in 
the  origin  of  puerperal  septicgemia,  and  granted  the  possibility  of  infection 
by  putrefactive  germs,  the  question  arises.  Are  they  always  introduced  by 
the  attendant?  Can  a  woman  be  infected  by  organisms  which  find  their 
habitat  in  her  genital  tract  before  delivery;  i.e.,  suffer  from  auto-infection  ? 
Semmelweiss/*^  in  the  paper  which  laid  the  foundations  of  antiseptic  mid- 
Avifery,  claimed  that  she  might ;  and  he  has  had  able  supporters  (Ahlfeld,^^ 
Kehrer,"'  Kaltenbach,^^  etc.).  Working  along  this  line,  investigators  have 
reached  various  results;  Gonner,*^**  Thomen,™  and  others  failing  to  find 
pathogenic  organisms  in  women  not  previously  examined,  and  Winter,^^ 
DOderlein,^"  Widal,'^  and  Witte'^  discovering  them  in  a  large  proportion  of 
cases.  Yahle  '^  finds  that  the  vaginse  of  infants  remain  sterile  for  only 
tAvelve  hours  after  birth.  At  the  end  of  three  daj^s  he  discovered  strepto- 
cocci in  14.6  per  cent.,  staphylococci  in  4  per  cent,  of  cases.  Doderlein,^^ 
however,  in  his  consideration  of  195  cases,  succeeded  in  explaining  the  dis- 
crepancy in  these  results.  He  discovered  that  there  are  tAvo  A'^aginal  secre- 
tions, normal  and  pathological,  the  one  containing  yeast  occasionally,  epi- 
thelium, and  a  non-pathogenic  bacillus  vaginae  Avhich  secretes  lactic  acid ; 
the  other,  numbers  of  micro-organisms  (streptococci  in  10  per  cent,  of 
cases).  Williams  ^^  has  confirmed  these  results  in  15  cases,  4  of  Avhichwere 
normal  (55.3  per  cent.  Doderlein).  In  8  cases,  pyogenic  microbes  were  dis- 
covered. Witte,^^  of  Berlin,  reports  53  examinations  on  the  same  lines.  It 
must  be  granted  that  it  lies  within  the  reahus  of  possibility  for  these 
pathological  cases  all  to  have  childbed  fever  resulting  from  auto-infection. 
HoAV  can  the  enormous  proportion  (44.6  per  cent.  Doderlein)  of  these  cases 
be  reconciled  with  the  results  obtained  by  Mermann,^^  who  shows  a  mor- 
tality of  6  per  cent,  in  900  labors,  recording  every  fever  over  100  degrees; 
by  Leopold,^^  Avho  in  919  finds  just  2  cases,  or  0.21  per  cent.,  in  AA^hich  there 
was  any  possibility  of  auto-infection ;  and  by  Hofmeier,'^  with  a  mortality  of 


150  REPORT   OF   THE   SOCIETV    OF    111 K    LVIXG-IX   HOSPITAL. 

o.«i  per  cent,  in  2,000  cases  ?  ^lennaim  used  only  sul)jecti\'e  antisepsis;  Leo- 
})ol(l  did  not  examine  his  women  at  all.  It  is  ap])arent  that  something  besides 
the  mere  jiresence  of  pathogenic  microbes  is  needed  to  ])roduce  se])tica'mia, 
Init  what  that  something  is  we  do  not  know.  It  is  known,  however,  that 
streptococci  and  st<iphylococci  have  been  introduced  into  fresh  wounds  "with- 
out result  (Bossowskv,~'  AVelch  '^).  Moreover,  it  is  possible  that  the  genital 
secretion,  e.(/.,  the  lactic  acid  foi-mod  by  I)oderlein''s  bacillus,  as  proved  l)v 
AVitte/-  inhibits  their  activity,  for  pure  cultures  of  streptococci  have  been 
found  by  Czerniewsky  ®  and  von  Franque**  in  healthy  uteri.  Kronig'^ 
has  added  by  his  researches  further  confirmation  to  this  theory  of  inhibi- 
tion. His  cases  number  forty-eight.  In  them  he  found  that  not  only  is 
the  vagintU  secretion  in  normal  pregnancy  free  from  germs,  but  that  it  pos- 
sesses actual  germicidal  power.  This  is  true  of  both  varieties  of  secretion, 
normal  aiul  ])athological.  Various  organisms  were  introduced  into  the 
vagina.  Streptococci  were  destroyed  first,  staphylococci  and  pyocyanei 
linng  twice  as  long.  The  resisting  power  of  the  tissues  is  the  same  to 
si)ores  and  cocci,  the  genital  tract  being  free  in  two  days,  at  the  longest, 
after  introduction.  His  conclusion  is,  that  ]:>rophy lactic  syringing  should 
be  given  up  even  in  cases  of  gonorrhoea,  since  this  germicidal  power  is  lost 
thereby.  liumm'*^  has  recently  stated  that,  aside  from  cases  of  acute 
septic,  gonorrhoeal,  or  tuberculous  endometritis,  chronic  endometritis  of 
the  body  and  neck  of  the  uterus  is  not  of  microbic  origin.  In  some  in- 
stances, microbes  were  found  in  the  secretions,  but  never  in  the  tissues,  and 
they  must  be  regarded  as  chance  visitors  of  no  importance.  He  does  not 
believe  that  chronic  endometritis  is  invariably  due  to  acute  or  subacute 
septic  or  gonorrhoeal  infection,  but  grants  that  by  microbic  invasion  the 
secretion  may  become  purulent. 

Menge,"  discussing  Bumm's  statement,  declared  that  in  71  examina- 
tions of  uteri  removed  in  Zweifel's  clinic,  he  has  never  found,  either  in  the 
secretions  or  tissues  of  the  uterine  or  cervical  cavities,  any  micro-organisms 
capable  of  existence  on  ordinary  culture  media.  The  same  holds  true  as 
regards  normal  organs  and  in  the  prcisence  of  chronic  endometritis.  In 
view  of  these  careful  investigations,  it  seems  probable,  at  least,  that  the 
uterus  may,  and  often  does,  remain  germ-free,  even  when  the  vaginal  secre- 
tion is  ])athological,  by  virtue  of  its  antise])tic  power  ;  and  the  mystery  of  a 
<».♦;  j)er  cent,  mortality  in  2,000  la])ors  remains  so  no  longer.  Walthard  ^" 
expresses  the  idea  in  another  way — that  the  cervical  canal  is  the  border 
between  those  ])ortions  of  the  genital  ti'act  which  are  free  from  l)acteria 
and  those  which  contain  them,  and  Ixdieves  with  Bumm  that  the  sapro- 
phytic germs  are  non-viruhjnt  on  healthy  tissue,  but  become  ])aTasitic  when 
the  resistance  of  tho.se  tissues  is  diminislMid.  The  mechanism  (»r  labor 
througliout  is,  moreover,  such  as  to  offej-  tli(!  least  oi)])ortunity  loi-  tli(!  en- 
trance of  organisms  from  the  vagina  and  cervix  into  the  uterus.  AVith 
regard  to  auto- inf(!ction  as  to  saprajmin.  wliilr  its  existence  must  be  ad- 
mitted, the  number  of  actual  cases  is  small  enough  to  be  ])assed  ov(m\ 

Twelve  of  our  cases  were  examined  bactcriologically,  tube  cultures 
being  ma<if  in  tin-  usmil  \v;iy,  wifh   ;i  swiib.  t  liroii«;ii  a  stcrili/cd  ^jlass  lulx;. 


THE   PREMATURE    INTERRUPTION    OF    PREGNANCY. 


151 


from  vagina  and  uterus,  botli  before  and  after  o])eration  and  at  the  end  of 
the  puerperium;  four  cultures  in  most  instances,  and  in  some,  six,  as  cul- 
tures at  the  end  of  the  puerperium  were  not  always  obtained.  The  vagina 
was  found  to  be  sterile  in  two  cases  of  the  12;  i.e.,  no  growth  of  bacteria 
appeared  on  the  media.  Of  the  pathogenic  organisms  occurring  in  six  cases, 
or  50  per  cent. ,  the  streptococcus  appeared  once  Avith  tlie  diplococcus  sub- 
flavus  of  Bumm;  the  sta])hylococcus  albus  twice,  with  the  bacillus  coli 
communis  once,  alone  once;  the  staphylococcus  aureus,  once  with  the  ba- 
cillus coli  communis ;  the  bacillus  coli  communis  with  the  bacillus  fluores- 
cens liquefaciens  once,  besides  the  instances  mentioned.  Red  yeast  was 
cultivated  from  one  vagina,  and  Bumm's  diplococcus  albicans  from  another. 
A  plate  exposed  half  an  hour  in  the  room  of  the  patient  in  the  first  of  the 
latter  two  cases  showed  colonies  of  sarcina,  red  yeast,  penicillium  glaucnm, 
staph^dococcus  albus,  and  bacillus  subtilis  and  liquefaciens.  In  one  of  the 
cases  in  which  staphylococcus  albus  and  bacillus  coli  communis  occurred 
together,  an  air  plate  from  the  room  showed  besides  various  fungi  only  the 
staphylococcus.  (Two  of  the  twelve  tubes  were  broken  in  transit.)  In 
these  examinations,  then,  the  white  staphylococcus  figured  three  times,  the 
bacillus  coli  communis  four  times,  the  golden  staphylococcus  and  strepto- 
coccus once  each. 

Below  is  a  table  showing  these  results: 


ORGANISMS    FOUND. 

Case 
ISTumber. 

VAGINA. 

UTEKUS. 

Before 
Operation. 

After 
Operation. 

Before 
Operation. 

After 
Operation. 

7,211 
7,465     1 

7,683 

7,177 

7,167    -j 
7,"l07 
7,034    1 

7,029     1 
7,022 

Red  yeast. 
Staph,  aureus.     \ 
Bac.  coli  com.     j" 
Sterile. 
(Broken.) 
Staph,  albus. 
Bac.  coli  com. 
Diplococcus  albic. 
Staph,  albus.       j 
Bac.  coli  com.     f 
Streptococcus. 
Diplococcus  subf. 
Sterile. 
(Broken.) 
Staph,  albus. 
Bac.  coli  com. 
Bac.  fluorescens. 

(Air  plate.) 
Sterile. 

a 

Staphylococcus  \ 
albus.                f 
Sterile. 

Bacillus  coli  com. 

\ 

Sterile. 
Sterile. 

a 
a 

a 

ii 

a 

a 
u 
u 

a 

Sterile. 
Sterile. 

a 

a 

a 
a 

f 

a 

6,924 
6,909 

6,891     1 

Sterile. 

a 

152  REPORT   OF   TIIK    SOCIETY    OF   THE    LYIXCMN    HOSPITAL. 

After  operation,  in  seven  enltures,  live,  or  71.4  per  cent.,  were  sterile, 
the  other  two  showing  bacillus  coli  communis  and  staphylococcus  once  each. 
Thirteen  examinations  of  uteri  were  made  before  operation  without  tlie  dis- 
covers' of  an  organism  of  any  kind,  and  the  same  result  was  obtained  in 
eleven  instances  immediately  after  o])eration.  One  culture  made  from  the 
vao"inal  fornix,  at  the  end  of  the  ]merperium,  showed  the  white  staphylo- 
coccus. 

Case  6,880  gave  sterile  culture  from  the  uterus  before  operation;  case 
6,915,  staphylococcus  albus  in  the  vagina  at  the  end  of  the  puerperium ; 
case  6,855  showed  the  same  in  the  vagina,  the  uterus  being  sterile  at  the 
end  of  the  puerperium. 

These  investigations  bear  out  in  a  striking  way  Doderlein's^  assertion 
that  the  uterus  of  tlie  normal  lying-in  wonum  is  germ-free.  No  division 
was  made  in  them  into  normal  and  pathological,  but  it  seems  fair  to  infer 
that,  even  in  the  ])resence  of  a  pathological  vaginal  secretion,  the  uterus 
mav  jiersist  in  its  freedom  from  invasion.  No  mention  is  made  l)y  the 
l)acteriologist  of  the  vaginal  bacillus  of  Doderlein.  The  occurrence  of  the 
bacillus  coli  communis  is  in  greater  proportion  than  previously  reported  (25 
]jer  cent.);  this  is  not  a  surprising  condition,  however,  considering  the 
]iroximity  of  the  rectum,  its  ordinary  habitat.  Buimn'^^  declares  that 
inoculation  upon  animals  is  necessary  to  prove  the  virulence  of  these  organ- 
isms, and  he  seems  to  be  correct,  in  view  of  the  minute  proportion  of  auto- 
infection  in  Mermann's  and  Leopold's  reports.  It  has  not  been  done  in 
anv  of  our  cases,  but  it  is  interesting  to  compare  the  clinical  histories  Avith 
the  bacteriological  findings. 

Case  6,855. — Abortion  (?).  Foetus  passed  forty-eight  hours  before 
examination.  Placenta  and  membranes  found  in  uterus  and  removed  manu- 
ally, rterus  curetted.  Douche  of  sublimate  solution  (^oVir)  and  packing 
of  iodoform  gau/.e.  Ten  days  later,  a  culture  from  vagina  showed  staphylo- 
coccus albus,  uterus  sterile.  No  fever.  (Absence  of  fever  in  presence  of 
sta])hylococcus  albus.) 

Case  6,SK0. — r)'imii)ara;  seventh  month  gestation;  seen  in  second  stage 
of  laijor,  which  lasted  nine  hours.  Tem])erature,  101.2  degrees;  pulse,  107 
when  seen;  placenta  manually  extracted,  adherent,  markedly  fatty,  and 
tf^rn  in  extraction.  Duration  of  third  stage,  thirty  minutes.  Pieces  of 
placenta  left  in  uterus  removed  as  far  as  possible.  Twenty- four  hours 
later,  temperature,  103;  ])ulse,  120.  Chloroformed,  external  genitals  and 
vagina  cleansed  with  lysol  (five  per  cent.)  and  sublimate  solution  {i^^^). 
Uterus  curette<l  with  dull  curette.  Pieces  of  placenta  and  nu;ndn'anes 
brought  away.  Irrigated  uterus  with  sublimate  solution  (s^oo)  and  ])acked 
it  with  gauze,  ('hill  immediately  followed.  Temperature,  104  degrees; 
pulse,  120.  Temperature,  101  to  lo;5  degrees  for  four  days.  Gauze 
removf;<l  on  second  day.  Examination  sIiowcmI  ut(!rus  bound  down,  and 
));ir;ini<;tritis.  After  treatment,  intrauterine  and  vaginal  douches.  No 
fouliHJSsof  lochia.  Discharge  on  tenth  day.  No  ])yrexia,.  Pulse  normal. 
Culture  from  uterus  showed  absence  of  any  organisms  hefore  operation. 
(F'ever,  with  no  oi-ganisms  ])resent  in  iitciiis.) 


THE    PltEMATURE    INTERRUPTION   OF    PREGNANCY.  153 

Case  6,891. — II.  pcara,  age  31,  tliii'd  iiionth.  Al)ortion  brought  about 
by  strain  forty-eight  hours  before  being  seen.  Bleeding  and  pain.  Uterus 
sensitive,  large,  antefiexed ;  shreds  of  membranes  hanging  from  os.  Cul- 
ture from  vaginal  fornix  showed  colonies  of  bacillus  coli  communis  and 
bacillus  tluorescens  non-liquefaciens.  Cervix  dilated  with  sterilized  Good- 
ell  dihitor,  and  culture  taken  from  fundus,  which  was  foand  to  be  ster- 
ile. Uterus  irrigated  Avith  sublimate  solution  (soVu)  ^^^^^^  curetted  with 
dull  and  sliarp  curette.  ISTo  foetus  found.  Pieces  of  membrane  removed. 
After  operation,  culture  from  fornix,  which  remained  sterile.  Yagina 
previously  wiped  with  absorbent  cotton.  Uterus  ])acked  with  iodoform 
gauze.  Removed  after  seventy-two  hours.  Discharged  on  fifth  day.  No 
pyrexia.     (Bacillus  coli  communis  present,  without  fever.) 

Case  6,915. — lY.  para,  fourth  month.  First  seen  August  20,  1894,  at 
11.30  A.M.  Temperature,  101  degrees;  pulse,  72.  Headache  and  dizziness 
for  two  weeks  past.  Hasmorrhage  and  pain  during  last  twenty-four  hours. 
External  os  open.  Seen  again  after  seven  hours.  Yagina  filled  with  clots. 
Os  admits  two  fingers,  and  membranes  protrude.  Ovum  removed  intact. 
Temperature,  99.2  degrees;  pulse,  80.  After  five  and  a  half  hours,  ether 
given  and  uterus  curetted.  A  few  pieces  of  membrane  and  clots  removed. 
Uterus  irrigated  with  sublimate  solution  (t 0^017)  ^^^  packed  with  iodoform 
gauze.  Gauze  removed  after  five  days.  No  fever  after  curettage.  No 
fetor  in  lochia.  Discharged  on  tenth  day.  Culture  made  from  posterior 
fornix  at  end  of  puerperium  showed  staphylococcus  albus.  (jSTo  fever 
after  curettage  with  staphylococcus  present.) 

Case  6,924. — YII.  para,  age  30.  One  previous  abortion.  Third  month. 
Firstseen  August 21,  1891:.  Temperature,  100 degrees;  pulse,  108.  Yagina 
full  of  clots.  Placenta  protruding  from  os.  Culture  from  posterior  fornix 
broken  in  transit.  External  genitals  and  vagina  cleansed  with  soap  and 
water,  lysol  solution  (five  per  cent.),  and  sublimate  (tijott)-  Culture  from 
fundus  of  uterus  sterile.  Placenta  removed,  uterus  curetted,  and  irrigated 
with  sublimate  solution  (-g^oVo^)-  Second  culture  from  fundus  uteri  and  fornix 
both  sterile.  Curetting  removed  several  pieces  of  membrane.  Uterus 
packed  with  gauze,  which  was  removed  after  seventy-two  hours.  Tempera- 
ture, 100.6  degrees;  pulse,  114  on  third  day;  temperature,  101.8  degrees; 
pulse,  107  on  sixth  day.  Constipation  throughout  puerperium.  No  odor 
from  lochia.      Discharged  on  eleventh  day.    (Fever,  with  sterile  cultures.) 

Case  7,022. — II.  para,  age  24,  third  month.  First  seen  September  3, 
1894,  at  1.30  a.m.  Found  patient  suffering  from  heemorrhage,  w^th  foetus 
lying  in  bed.  Pain  and  hgemorrhage  for  five  hours.  Packed  with  iodoform 
gauze,  which  was  removed  after  ten  hours,  and  placenta  found  in  os.  Cul- 
tures from  fornix  and  fundus  both  sterile.  Uterus  irrigated,  curetted, 
irrigated  again,  and  second  culture  taken  from  it  also  sterile.  Placenta 
and  membranes  rotten ;  foetus  evidently  dead  some  time  previously.  Gauze 
removed  from  uterus  at  end  of  forty-eight  hours.  No  record  of  pulse  and 
temperature  before  operation;  afterwards,  pulse,  106;  temperature,  101.1 
degrees.  Fever  undoubtedly  present  when  first  seen.  (Fever  case,  with 
rotten  decidua,  but  no  bacteria  or  other  organisms  discoverable. ) 


15-4  REPORT   OF   THE   SOCIETY    OK   THE    LYIXG-IX    HOSPITAL. 

Case  6,900. — II.  para,  a^o  10.  When  first  seen,  fivtus  found  in  bed, 
vao-ina  filletl  with  clots,  ami  idacenta  in  cervix.  Vau-ina  packetl  with 
sterilized  gauze.  After  ten  hours,  operation  under  ether.  Genitals  and 
vagina  cleansed  in  usual  way.  Uterine  douche  of  bichloride  (Wuir)- 
Scraped  with  dull  curette  and  decidua  removed.  Again  douched  with  sub- 
limate solution.  No  fever.  Discharged  on  seventh  day.  Culture  from 
vagina  before  operation  showed  staphylococcus  albus.  Other  three  cul- 
tures sterile.     (No  fever  in  presence  of  staphylococcus  albus.) 

Case  T,o20. — A^II.  para,  age  32,  two  and  one-half  months.  Seen  first 
September  3,  ISO-t.  Gave  history  of  pain  and  luemorrhage  for  a  few  days 
past.  Had  passed  pieces  of  decidua.  Curettage  shortly  after.  Decidua, 
but  no  foetus,  removed.  Uterus  packed  Avith  gauze,  whicli  was  removed 
four  days  after.  No  fever.  Discharged  on  seventh  day.  The  stre])- 
tococcus  and  diplococcus  subflavus  were  found  in  the  vagina  before  o])- 
eration;  the  uterus  sterile  throughout.  (Xo  fever.  Stre])t()coccus  in 
vagina.) 

Case  7,034. — III.  para,  age  o-t,  fourth  month.  Seen  September  3, 
181I4.  Ibemorrhage  for  week  past.  Sharp  lijemorrhage  at  time  of  visit; 
teni])ei'ature,  100  degrees;  ]mlse,  Oo.  Foetus  at  vulva  attached  to  placenta. 
Uterus  curetted,  removing  decidua.  Uterus  and  vagina  packed  with  gauze, 
which  was  removed  in  four  days.  No  pyrexia,  no  lochial  odor.  Dis- 
charged on  eleventh  day.  Culture  from  vagina  before  operation  showed 
Ijacillus  coli  communis  with  staph^dococciis  albus ;  after  operation,  bacillus 
alone,  while  uterus  remained  sterile.  (Virulent  pathogenic  organisms, 
with  no  fever.) 

Case  7,107. — A"IL  para,  age  3o.  Seen  September  13,  1801:.  Bleeding 
for  one  week.  Treated  by  midwife  and  private  physician.  Pale,  exsan- 
guinated, chills;  temperature,  00  degrees;  pulse,  llo.  Uterus  one  and  one- 
half  inch  above  pubis,  and  sensitive.  Cervix  hard  and  closed.  Vagina 
hot  and  dry.  Curetted.  Decidua  and  small  ]iiece  of  ])lacenta  removed. 
Packed.  No  fever,  no  tenderness  of  uterus.  Diplococcus  albicans  of 
Bumni  found  in  vagina  before  operation.  No  organisms  discovered  there 
afterwards.     (No  fever  and  no  pathogenic  organisms.) 

Case  7, Km. —  X.  para,  age  4-2,  eighth  niontli.  Placenta  adherent  to 
uterine  wall  and  manually  removed.  Douched  with  sublimate  solution 
(rslooj-  T('m[)('i-atui'('  a  few  hours  aftei-  labor,  lol.l-  degrees;  pulse,  '02. 
Temperature,  lol  to  Jo:^,  degrees  for  foui-  davs.  Tliii-d  day,  tympanitic 
and  tende*r  abdomen.  I.ai-ge,  soft  uterus.  Cui-cttc^d,  I'emoving  small 
pieces  of  deci<lua;  douched  and  packed  uterus.  Ciauze  removed  on  fourth 
day.  Tem]>erature,  lOl  degrees  on  liHii  day.  Discharged  on  eleventh 
day  in  fair  condition.  The  staphylococcus  albus  t'ouiul  in  vagina  before 
an<l  after  operati(jn  ;  bacillus  coli  couiuniiiis  in  (•()iMl)inati<m  before. 
Uterus  sterile.  (Fever.  se|)ti<;eiiHa.  willi  b.icjiiiis  cdM  .ind  sta])hylococcus 
]jresent  in  vagina. ) 

Ca.se  7,177. — II.  ])ara,  age  li'.'.  iliinl  uioulli.  Midwil'c  in  aLtondance 
two  days  when  seen.  Fterine  lia-inorriiage  ])ersistent.  Uterus  curetted, 
douched,  and    |)acked.      (liiu/.e    rcinoNcd    in    t'oui'   d;iys.       Xo   fever.       No 


THE    PREMATURE    INTERRUPTIOX    OF    PREGNANCY.  155 

lochial  odor.     Discharged  on  tenth  day.      Tul^e  from  vagina  before  opera- 
tion broken;  other  three  cultures  sterile.     (Xo  fever,  no  organisms.) 

Case  7,683. — III.  para,  age  28,  fourth  month.  Foetal  head  found  pro- 
truding from  vagina.  Foetus  removed  manually,  placenta  and  memljranes 
adherent.  A  few  hours  later  curetted,  washed,  and  packed  uterus  with 
gauze,  which  patient  removed,  substituting  a  sponge.  ISTo  fever.  Dis- 
charged in  good  condition.  Sterile  cultures  throughout.  (Xo  fever.  Xo 
organisms.) 

Case  7,165. — Four  previous  abortions.  Three  and  one-half  months. 
Pain  and  haemorrhage.  Yagina  full  of  clots.  Uterine  cavity  three  inches 
lono-.  Foetus  and  placenta  found  in  clots  discharged.  Curetted,  douched, 
and  packed.  Gauze  removed  on  third  d?ij.  Lochia  sweet.  Xo  fever. 
Discharged  eighth  day.  Culture  from  vagina  before  operation  showed  ba- 
cillus coli  and  staphylococcus  aureus ;  the  other  three  sterile.  (Xo  fever, 
with  bacillus  coli  and  staphylococcus  aureus  present.) 

Case  7,211. — TV.  para,  age  26;  third  month.  Had  bled  profusely. 
Vagina  packed  with  gauze.  Four  hours  later  uterus  scraped,  douched,  and 
packed.  Mass  of  decidua  removed.  Xo  fever  or  other  complications. 
Patient  removed  gauze  on  third  day,  and  refused  further  treatment.  Eed 
yeast  only  was  found  in  the  four  cultures,  although  a  plate  exposed  to  air 
of  room  showed  colonies  o|  staphylococci.  (Xo  fever  and  no  pathogenic 
organisms.) 

These  fifteen  histories  furnish  some  curious  data  and  not  a  little^  food 
for  reflection.  Among  them  we  find  an  absence  of  temperature  above 
100.5  degrees  and  of  other  svmptoms  of  infection  in  childbed  no  less  than 
seven  times  {4:6.6  per  cent,  of  cases,  or  nearly  one-half),  when  organisms  of 
whose  virulence  under  ordinary  conditions  there  can  be  no  doubt  Avere 
found  in  the  vagina  before  and  often  after  operation,  possibly  continuously 
present.  If  any  inferences  can  be  drawn  from  so  small  a  number,  there 
must  be  some  virtue  in  genital  antisepsis,  or  else  vaginal  secretions  dimin- 
ish to  a  marked  degree  the  pathogenic  power  of  these  microbes.  Hardly 
less  striking  are  the  three  cases  (20  per  cent.)  in  which  fever  and,  in  case 
7,022,  a  marked  degree  of  septiceemia  with  putrid  decidua  occurred  with- 
out a  growth  of  any  kind  appearing  on  the  media.  Four  times  the  nat- 
ural order  of  coincident  absence  of  fever  and  micro-organisms  appeared 
(26.6  per  cent.),  and  once,  that  of  presence  of  the  two  (6.6  per  cent.).  In 
other  words,  of  the  fifteen  cases,  four  had  symptoms  of  septic  infection 
and  one  only  showed  pyogenic  microbes  in  her  secretions.  There  Avas  no 
interference  by  midwives  in  this  instance,  and  the  continuous  presence  of 
the  staphylococcus  albus  in  the  vagina,  with  the  addition  of  the  bacillus 
coli,  before  operation  at  least,  appears  to  offer  some  ground  for  the  theory 
of  auto-infection. 

A  chapter  on  the  bacteriology  of  the  lying-in  period  cannot  be  consid- 
ered complete  without  some  mention  of  the  gonococcus.  It  was  not  found 
in  our  observations,  the  people  from  whom  they  were  drawn  enjoying  a 
remarkable  immunity  from  venereal  disease.  The  present  state  of  our 
knowledge  of  gonorrhoea  of  the  uterus  has  been  satisfactorily  summed  up 


156  KEPORT   OF   THE   SOCIETV   OF   THE    LYING-IX    HOSPITAL. 

bv  AVortlioiin  ^'  at  the  recent  meeting  of  the  German  Gyna?colog-ical  Society. 
His  dethictions  are  these:  next  to  the  urethi-a,  the  uterus  is  the  most  fre- 
ijuent  seat  of  disease.  Infection  is  usually  direct,  and  is  often  confined  to 
the  uterus  alone.  Gonorrhcval  vaginitis  is  comparatively  a  rare  aflfectiou. 
An  acute  and  chronic  stage  of  uterine  gonorrhcva  is  clinically  distinguish- 
able, although  a  sharp  line  caniu^t  be  di'awn  l)et\veen  them.  Infection 
gives  rise  to  ])urulent  endometritis,  the  secretion  containing  numberless 
cocci;  but  as  the  discharge  lessens,  they  become  fewer,  and  are  replaced  by 
other  bacteria.  AVertheim  found  cocci  in  eight  of  eighteen  uteri  removed, 
faOing  to  discover  them  in  six  cases  with  clear  history.  There  is  almost 
always  an  acute  interstitial  endometritis  ])resent,  resulting  finally  in  iutil- 
tration  of  the  muscle,  with  hyperplasia  of  the  vessel  walls,  and  a  replace- 
ment of  the  muscle  fibres  by  connective  tissue.  Enlargement  and  pain  in 
the  organ  are  evidences  of  this  condition.  In  a  certain  number  of  chronic 
cases  there  is,  besides  an  increase  of  the  glandular  structure,  glandular 
endometritis.  Inflammatory  change  becomes  less  marked  as  the  external 
OS  is  a)))iroached.  Gonococci  are  found  most  readily  in  the  mucosa,  with 
difficulty  in  the  deeper  tissues.  Mixed  or  secondary  infection  is  as  rare  as 
in  gonorrhceal  salpingitis.  The  internal  os  offers  no  barrier  to  the  ascent 
of  the  process,  shown  by  the  presence  of  cocci  in  the  endometrium  when 
the  adnexa  were  apparently  healthy  (five  cases  examined).  Exacerbations 
are  due  t(j  menstruation,  coitus,  and  intrauterine  treatment,  dependent  on 
alterations  in  the  nutritive  medium,  although  there  is  always  a  possibility 
of  reinfection.  The  puerperium  is  a  peculiarly  unfavorable  state,  since  an 
invasion  of  previously  unaffected  parts  takes  place  frequently. 

Etiology. 

A  study  of  our  (535  cases  of  the  imtimel}'  interruption  of  pregnancy 
shows  that  the  causes  of  the  accident  have  but  rarely  been  positively  ascer- 
tained. It  must  be  remembered  in  this  connection  that  all  of  the  G35  cases 
treated  were  cared  for  in  an  outdoor  dispensar}'  practice,  in  the  patients' 
own  homes;  that  the  majority  (see  Table  of  Nativity)  was  made  up  of  the 
ignorant  foreign  ])0]uilation  of  rlic  lower  East  Side  of  the  city,  many  of 
whom  liad  been  but  a  short  tinu;  in  this  country,  and,  through  ignorance, 
were  unal)le  to  give  anything  approaching  a  definite  history  regarding  the 
character  of  tlieir  ])rec(!ding  interrupted  pregnancies,  lal)ors  at  term,  })uei-- 
peria,  or  ])re(!xisting  uterine  disease. 

Kecords  of  the  evidence  of  preexisting  oi-  ])r('sent  disease  of  the  uterus 
are  lacking  in  most  of  oui-  liistories,  and  tliis  fact  is  ])artly  explained  ])y  the 
nature  of  our  service  and  the  com jia rati vely  short  time  that  ])ati(;nts  Avould 
8ul)mit  to  treatment.  For  example,  the  avei'age  duiution  of  after-treat- 
iiHMit  wiis  as  ioljows: 


THE   PREMATURE   INTERRUPTION   OF   PREGNANCY. 


157 


Average  Duration  of  Treatment.* 

Early  abortions 7  days  8  hours. 

Late  abortions 7  days  21  hours. 

Premature  labors 9  days  7  hours. 

The  first  visit  and  first  examination  of  the  patient  in  our  early  and  late 
abortions  were  usually  made  by  one  of  the  resident  staff  officers,  after  the 
lapse  of  a  considerable  period  from  the  onset  of  the  first  symptoms.  This 
is  shown  in  the  subjoined  table: 

Duration  of  Symptoms  when  First  Seen. 


EARLY    ABORTIONS. 

129  Observations. 


LATE    ABORTIONS. 

57  Observations. 


Average  duration 
Longest        " 
Shortest       " 


3  days  22  hours. 
3  weeks. 
10  minutes. 


6  days  19  hours. 

7  weeks. 
1  hour. 


The  staff  physician  at  this  first  examination  endeavored  to  ascertain 
only  those  conditions  which  call  for  immediate  treatment;  for  instance,  in 
abortion  the  amount  of  hgemorrhage  and  the  character  of  the  abortion.  In 
this  way  the  more  minute  changes  in  the  condition  of  the  uterus  and  its 
appendages,  which  are  associated  with  preexisting  or  present  uterine 
disease,  escaped  observation.  This  fact  is  true  of  our  earlier  cases,  but 
only  partly  true  of  our  later  ones.  For  since  the  appointment  of  a  bac- 
teriologist to  the  Hospital  in  1894,  bacteriological  examinations  of  blood, 
of  uterine  and  vaginal  secretions,  both  before  and  after  operative  interfer- 
ence, have  been  made.  Moreover,  decidual  scrapings  have  been  preserved 
and  subjected  to  examination  for  evidences  of  disease  (see  Bacteriology  and 
Pathology), 

*  Duration  of  Treatment. — Abortion  Cases. 


early  abortions. 
206  Observations. 

late  abortions. 
157  Observations. 

Average  duration 

7  days  8  hours. 
28  days. 
Iday. 

7  days  21  hours. 
18  days. 
Iday. 

Longest        "         

Shortest        "         

Duration  of  Treatment  in  Spontaneous  Premature  Labor  Cases. 
In  143  Observations. 

Average  duration,    9  days  7  hours. 
Longest  "  40  days. 

Shortest  "  1  day. 


15S  REPORT   OF   THE   SOCIETY    OF   THE    LYING-IN    HOSPITAL. 

Umluubtodly  [)artit-ular  stress  sliuukl  be  laid  upDii  certain  anomalies 
c»i'curring  in  previous  untimely  interruptions  of  pregnancy,  labors  at  term, 
and  puerperia,  as  these  usually  are  the  first  expression  of  beginning  uterine 
disease  or  the  direct  ])recursor  of  such,  but  unfortunately  our  histories  for- 
bid anv  accurate  statements  in  this  dii-ection.  As  has  been  frequently 
pointed  out  by  different  observers,*  a  striking  feature  in  the  study  of  etioL 
ogv  is  the  number  of  preceding  premature  interru]itions  of  pregnancy. 

To  render  this  point  more  gra[)hic  in  regard  to  our  cases,  "we  have  con- 
structed the  following  tiibles. 

Pkkvious  Untimely  Intekkuptions  of  Pregnancy  in  Abortion  Cases. 

23  alK)rtion  cases  experienced 1  previous  abortion. 

(*)         ••  "  "  2         ''        abortions. 

1  ..  a  u  2  u  u 

1  ''        case  "  4         "  " 

2  "        cases  "  5         "  " 

9  u  u  i(  Q  i(  i( 

38 

54  abortion  cases  experienced . .   1  previous  premature  labor. 
17         "  "  "  .  .   2         "  "        labors. 

-IK  i'  a  i(  3  "  <'  '' 

-19  a  u  (I  A  u  a  ii 

I  u  a  a  K  a  a  a 

1         "        case  "  ..   6         "  "  " 

103 

Total  number  of  al)ortion  cases  that  experienced  previous  abortions,  3.8, 
or  IM  ])er  cent. 

Total  number  of  abortion  cases  that  experienced  previous  premature 
labors,  lo;^>,  or  24.7  per  cent. 

Total  number  of  abortion  cases  that  experienced  previous  untimely 
interrupted  pregnancies,  141,  or  ?A  ])er  cent. 

Previous  Untlmklv  1n'ikkki;i'ti<jns  of  Pregnancy  in  Premature  Labor 

Cases. 

13  premature  labor  cases  experienced ...    I  ]>revious  abortion. 
1  "  "      case  "  ...    2         "        abortions. 

15 

*  Winckel  and  Stumpf  found  among'  15.5  of  flipjr  multipara^  who  aborted,  59,  or  .'{8 
|)fr  f<Mit.,  wln)  liad  previously  suffered  from  iiiU-rruplcd  prcj^uaiicics  ;  amouj,''  1)1:^  willi 
immature  lab«a',  2i'>,  or  28.5  percent. ;  wmon^  JOI  witli  ])remature  labor,  18,  or  17.8  per 
cent. ;  and  in  8  of  tliase  103  ca.ses  with  precedinj?  untimely  labors,  every  pregnancy 
had  been  a  |»rfmatur<'  f»Me  ;  .'5  were  .'iliortions.  I  iinin.ifun'  l.ibors,  and  only  1  prema- 
ture lalxir. 


THE   PREMATURE    INTERRUPTION    OF    PREGNANCY.  159 

17  premature  labor  cases  experienced  1  previous  premature  labor. 


(3 

a 

2 

lab( 

8 

iC 

3         " 

(( 

1 

case 

4         " 

a 

1 

u 

5         " 

(( 

1 

ii 

6         " 

ie 

Total  number  of  premature  labor  cases  that  experienced  previous  abor- 
tions, 15,  or  6.9  per  cent. 

Total  number  of  premature  labor  cases  that  experienced  previous  prema- 
ture labors,  41,  or  20.2  per  cent. 

Total  number  of  premature  labor  cases  that  experienced  previous  un- 
timely interruptions  of  pregnane}^,  59,  or  26  per  cent. 

The  most  strikiuo-  fact  shown  in  the  foreo-oino^  tables  is  the  large  num- 
ber  of  previous  untimely  interruptions  of  pregnancy  in  our  cases ;  for,  as 
the  tables  show,  among  417  women  who  aborted  (using  the  term  in  its 
broad  sense),  141,  or  34  per  cent.,  suffered  from  previous  premature  inter- 
ruptions of  pregnancy;  and  among  our  218  cases  of  premature  labor,  59, 
or  26  per  cent. ,  experienced  previous  untnuely  interruptions  of  pregnancy. 

Again,  the  fact  that  those  patients  who  aborted,  and  not  the  premature 
labor  cases,  were  those  who  previously  had  suffered  most  from  former  pre- 
mature interruptions  of  pregnancy  (34  per  cent,  as  against  26  per  cent.), 
substantiates  the  well-known  axiom,  referred  to  in  another  place  in  this 
article,  that  the  longer  existence  of  uterine  disease  leads  to  an  ever  earlier 
interru])tion  of  pregnancy. 

Traumata  and  fright  were  frequently  averred  by  our  patients  as  excit- 
ing causes  of  interrupted  pregnancy;  but  such  statements,  coming  from  the 
patients  themselves,  have  generally  been  disregarded. 

Criminal  Abortion.— The  suspicion  of  criminal  abortion  was  attached 
to  a  number  of  the  cases  here  studied,  but  in  what  proportion  criminal 
interference  entered  as  an  etiological  factor  is  unknown. 

Although  in  only  21  of  our  417  cases  of  abortion  do  the  histories  indi- 
cate that  mid  wives  were  in  attendance,  still  we  have  reason  to  believe  that 
the  midwife  was  responsible  for  a  number  of  these  premature  interrup- 
tions of  pregnancy.  It  is  a  significant  fact  that  the  professional  card  of 
a  midwife  was  frequently  found  in  the  patient's  apartment  upon  the  arrival 
of  the  physician  from  the  Hospital. 

We  have  ascertained  that  the  most  common  method  of  criminal  inter- 
ference among  the  patients  studied  in  this  article  is  for  the  midwife,  or  the 
patient  herself,  instructed  previously  by  the  midwife,  to  rupture  the  mem- 
branes by  means  of  a  knitting-needle  passed  through  the  os.  One  drug- 
gist on  the  lower  East  Side  is  said  to  do  a  large  business  in  tupelo  tents 
sold  to  midwives;  for  what  purpose  can  easily  be  conjectured. 

Statements  of  the  more  intelligent  midwives  are  to  the  effect  that  the 
Italians  of  the  district  covered  by  this  report  make  use  of  the  oil  or  the 
fluid  extract  of  sabina  (Juniperus  sabina)  to  terminate  an  inconvenient 


ICU  REl'OKT   OF   THK   SOCIETY    OF   THE    LYING-IX   HOSPITAL. 

pregnancy,   ami,    fiirthor,  that  the  ilrug  accoini)lishes   the  desired  result 
within  twenty-foui*  hours  of  the  first  dose. 

In  none  of  our  eases  was  legal  incjuirv  set  on  foot,  since  direct  i)roof  of 
criminal  interference  could  never  be  obtained. 

Porak,^  from  his  study  of  his  320  cases  of  early  and  late  abortions, 
could  ascertain  the  cause  of  the  accident  in  but  few  instances,  but  found 
the  most  frecjuent  anatomical  cause  to  be  alterations  in  the  decidua,  result- 
ing in  thickening  and  strong  adhesion  of  the  decidua  to  the  uterine  wall, 
after  expulsion  of  the  ovum. 

The  microsco])ic  examination  of  the  decidual  scrai)ings  in  our  cases  was 
only  set  on  foot  towai'd  the  end  of  our  series  of  4-17  cases,  and  we  have 
reports  of  only  seven  cases  to  offer,  the  findings  in  Avliicli  are  practically 
negative.     (See  Pathology.) 

Porak^  found  the  accident,  in  his  remaining  cases,  due  to  traumatism, 
32;  sN'pliilis,  32;  mental  emotions  and  fatigue,  22;  retroversion  of  the 
uterus,  13;  cardiopathy,  13;  typlioid  fever,  13;  pulmonary  tuberculosis, 
13;  albuminuria  and  eclampsia,  12;  twin  ])regnancy,  10;  defective  inser- 
tion of  the  ovum,  10;  and  scrofula,  8, 

Prion's  ^  critical  study  of  530  cases  of  abortion  is  most  instructive,  as 
well  as  interesting.     In  only  163  of  his  530  cases,  or  about  one  in  four, 
was  he  able  to  ascertain  the  cause  of  the  accident. 
The  causes  in  the  1G3  cases  were  as  follows: 

Cases. 

Faulty  insertion  of  the  placenta 64 

Syphilis 52 

Albuminuria 2Y 

Hydramnios 13 

Malformations  and  nuilposirious  of  tlic  uterus 7 

Total 163 

Prion  narroAvs  down  the  causative  factors  to  the  above  mentioned,  and 
draws  attention  to  the  fact  that  in  143  of  his  163  cases  of  abortion  the 
causative  factors  Avere  (1)  faulty  insertion  of  the  placenta,  64  cases;  (2) 
syphilis,  52  cases;  (3)  albuminuria,  27  cases.  lie  refers  to  the  statement 
of  liaudeloque,  namely,  that  "  the  insertion  of  the  placenta  near  the  cervix 
provokes  abf)rtion,"  and  to  the  recent  teachings  of  Pinard,  who  insists  upon 
the  influence  of  a  faulty  insertion  of  the  phicenta  at  tlie  internal  os  as  a 
fre(juent  causative  factor  in  tli(!  ])roduction  of  an  al)()i'tion. 

Prion's^  conclusions  r(;garding  the  64  cases  of  faulty  insertion  of  tlie 
placenta  are  founded  u[)on  carcfid  inspc^ction  and  measunjuunits  of  tlie 
membranes  in  each  case.  Tlic  into'cst  in  liis  study  centres  around  the  two 
conditions — faulty  or  ](>\v  iniphintation  of  the;  phicenta,,  and  albuminuria 
(t<jxa'miaj,  as  tln"  two  main  (-lusative  factors  in  tlu;  (etiology  of  his  cases. 
His  conclusions  in  this  direction  were  the  result  of  m(!thodical  and  ])ains- 
taking  examinations  of  the  decidua.  ])lacenta,  membranes,  and  mine  in 
every  woman  under  his  charire- 

Acc*^>rding   to    Pinard    and     i't  liling,    r<;nal    alterations   (insufficiency, 


THE    PREMATURE    INTERRUPTION    OF    PREGNANCY.  161 

nephritis)  cause  decidaal  liremorrhages,  and  the  character  of  the  abortion 
will  de[)end  upon  the  quantity  or  the  greater  or  less  repetition  of  these 
haemorrhages, 

Brion^-  does  not  pretend  to  limit  the  etiology  of  abortion  to  these 
three  causes  (faulty  insertion  of  the  placenta,  syphilis,  and  renal  disease), 
Init  merely  aims  to  show  what  in  his  opinion  are  the  most  frequent  causes. 
He  predicts  that  the  more  carefully  we  study  the  etiological  factors  of  our 
cases  the  fewer  will  we  find  falling  outside  of  these  three  causes.  He 
pleads,  moreover,  for  a  future  consideration  of  these  three  causes  in  formu- 
lating the  etiology,  prognosis,  diagnosis,  and  treatment  of  abortion.  His 
studies  induce  him,  when  in  the  presence  of  an  abortion,  the  cause  of 
which  is  not  evident,  not  to  ascribe  the  condition  to  criminal  interference. 

It  ma}"  here  be  asked  what  were  the  etiological  factors  in  our  417  cases 
of  abortion.  "We  reply  we  do  not  know.  "We  do  not  know,  because  few, 
if  any,  of  our  cases  were  under  observation  at  the  onset  of  the  attack  ; 
because  it  was  not  granted  to  us  to  make  urinary  analyses  before  the  occur- 
rence of  haemorrhage;  and  because,  in  our  earlier  cases,  postpartum  exami- 
nations of  the  urine  were  not  made;  and  because  the  results  in  the  few 
recent  cases  in  which  the  urine  was  examined,  were  practically  negative. 

In  only  six  instances  of  the  242  early  abortions  was  the  Hospital  phy- 
sician summoned  at  the  time  the  abortion  was  threatened;  in  only  48 
was  the  condition  inevitable;  so  that  in  the  remaining  188  cases  the 
conditions  were  those  of  complete  (14)  or  incomplete  (162)  abortions. 

In  late  abortions  our  histories  indicate  only  the  following  conditions  as 
the  probable  causes  of  the  accident : 

Causes  of  Late  Abortions. 

Cases. 

Death  of  foetus  (cause  unknown) 106 

Death  and  maceration  of  foetus  (cause  unknown) 19 

Multiple  (twin)  pregnancy 2 

Fault}"  implantation  of  placenta  (previa) 2 

]^ephritis  and  cardiac  disease 1 

Acute  syphilis  and  cardiac  disease 1 

Albuminuria  (toxaemia) 1 

Ketroflexion 1 

Hydatidiform  mole 1 

Alcoholism 1 

UnknoAvn  cause 40 

Total 1T5 

Spontaneous  Premature  Labor. 

In  spontaneous  premature  labor,  on  the  other  hand,  the  cause  of  the 

accident  was  quite  frequently  determined,  for  the  reason  that,  as  a  rule, 

these  of  our  cases  were  first  seen  by  a  Hospital  official  either  in  the  first  or 

second  stage  of  labor.      Thus,  the  following  table  indicates  the  period  in 

11 


102  REPORT   OF   THE    SOCIETY    OF   THE    LYING-IN   HOSPITAL. 

the  progress  of  labor  at   wliicli  (.mv  218  cases  of  spoutaueous  preniatiire 

labor  were  first  visitet I:  r^ 

Cases. 

In  the  first  stage  of  labor 125 

In  the  second  stage  of  labor 58 

In  the  third  stage  of  labor 20 

Not  noted  on  histories 15 

Total 218 

It  will  thus  be  seen  that  the  majority  (188)  were  under  observation  either 
in  the  first  or  in  the  second  stage  of  labor,  and  this  fact  enables  us  to  for- 
mulate the  etiolog}'  in  a  certain  number  of  cases.  The  facts  ascertained 
appear  in  the  following  table: 

Causp:s    of  Peematuke  Labor.  Cases 

Death  of  fo?tus 47 

Death  and  maceration  of  foetus 43 

Multiple  (twin)  pregnane}^ 19 

Faulty  implantation  of  placenta  (praevia) T 

Faulty  implantation  of  placenta,  and  twins 1 

Albuminuria  (toxaemia) 5 

Syphilis 1 

Syphilis  and  hytlramnios 1 

Antepartum  pneumonia 1 

Pulmonary  tuberculosis 2 

Cause  unlvnown 91 

Total 218 

Our  etiological  tables  of  late  abortions  and  spontaneous  premature 
labors  leave,  as  will  be  seen,  the  cause  of  the  accident  in  a  large  number 
of  instances  practically  unknown,  for  the  reason  that  the  cause  of  foetal 
death  and  maceration  in  the  cases  here  studied  is  undetermined. 

Tlie  part  played  by  paternal  and  maternal  syphilis,  b}?"  toxaemia  (albu- 
minuria), and  other  causes  of  intrauterine  death  of  the  foetus  which  escaped 
observation,  we  can  only  conjecture.  That  all  causes  which  kill  the  foetus 
may  produce  ])remature  interruption  of  pregnancy,  no  one  questions. 

The  large  number  (2ft)  of  multiple  pregnancies  found  among  the  spon- 
taneous ]iremature  labors  is  iiitei-esting.  Th(^  same  may  l)e  said  of  faulty 
ini))laiitatioii  of  the  ])lacenta  (8  cas(!s). 

Pinai-d  lias  sho\v?i,  as  ah'cady  I'eferred  lo  in  (|no1ing  ib'ion's  statistics 
of  the  causation  of  early  aljortions,  that  s))oiitaiU'ous  ])i'einature labor  isdu(\ 
in  a  large  proporti(jM  of  cases,  to  tlie  insei-tion  of  Ihc  ])]aceiita  in  the;  inferioi- 
segment  of  the  uterus.  I'inaril  has  furl  iM'rnioi'c  sliown  lliatthi^  ])r(Mna- 
turc  ru]»tui"e  of  the  ni('iMb)-an(;s,  wliicii,  as  a  I'ule,  ac(;o)ii panics  a  low  im- 
plantation of  the  placenta,  is  the  (hitermining  cause  of  the  prenuiture 
interruption  of  jtregnancy. 

In  regard  to  our  91  cases  of  spontaneous  jirematun^  labor  in  which  the 
cause  wa.s  unknown,  it  jnust  not  be  forgotten  that  certain  women  always 
have  short  pregnancies,  and  children  that,  though  undersized,  do  well. 


the  premature  interruption  of  prkgnancy.  1g3 

Prognosis. — Complications. 

1.   IRvmorrh(uje. 

Ilaenioi'i'liage  is  a  complication  of  Importance.  Misracbi  '^  found  in  1)2 
cases  the  curette  indicated  for  it  13  times,  as  against  four  cases  of  sepsis. 
(Ilis  controversy  Avith  Porak  on  this  subject  will  be  found  reviewed  under 
Treatment. )  The  statistics  of  our  cases  offer  us  no  valuable  data  as  to  the 
f requeue}^  of  haemorrhage  and  the  necessity  of  interference  for  it,  since  an 
early  intervention  has  been  the  custom  of  the  Hospital  physicians,  this 
having  for  its  object  not  merely  the  prevention  of  sepsis,  but  subsequent 
haemorrhage  as  well,  in  a  class  of  patients  prone  to  neglect  abortions.  Per- 
sistent haemorrhage,  though  slight,  induces  a  condition  of  weakness  emi- 
nently predisposing  to  infection  later.  Stumpf  shows  after-haemorrhages 
in  4.1  per  cent,  of  his  cases  under  expectant  treatment,  and  in  13.3  per 
cent,  of  those  manually  treated. 

A  study  of  our  statistical  tables  shows  that  haemorrhage  as  a  prominent 
symptom  was  noted  in  207,  or  85. 5T  per  cent,  of  our  242  cases  of  early 
abortion  before  treatment.  This  agrees  with  what  has  already  been  stated 
(see  Classification)  regarding  the  frequency  of  haemorrhage  in  early  abor- 
tions. After  treatment  in  early  abortions,  we  find  the  record  of  but  one 
case  of  haemorrhage. 

It  will  be  seen  under  the  head  of  Treatment  that  214  of  these  242 
cases  of  early  abortion  were  subjected  to  active  treatment;  namely,  curet- 
tage, and  that  in  129  instances  the  operation  was  performed  immediately 
after  arrival  of  the  Hospital  physician.  We  look  upon  these  results  as  an 
additional  argument  in  favor  of  an  active  treatment. 

In  our  175  cases  of  late  abortion,  Av^e  find  haemorrhage  as  a  prominent 
symptom  before  or  during  delivery  in  116  instances,  or  66.29  per  cent,  of 
cases.  After  delivery  and  treatment,  we  find  but  five  instances  of  hgemor- 
rhage.  Referring  once  more  to  Treatment,  it  will  be  seen  that  111  of  these 
175  cases  were  subjected  to  curettage,  and  that  the  operation  was  performed 
at  once  in  55  cases.  Regarding  the  third  stage  of  labor,  its  average  dura- 
tion was  44  minutes.  The  placenta  was  spontaneously  delivered  in  35, 
expressed  in  19,  manually  removed  in  26,  instrumentally  removed  in  87, 
and  of  8  cases  we  have  no  record. 

In  our  218  cases  of  spontaneous  premature  labor,  hsemorrhage  before  or 
during  delivery  is  noted  in  14  instances,  or  6.42  per  cent.,  and  haemorrhage 
after  delivery  in  4  cases.  Among  our  premature  cases  are  eight  of  pla- 
centa prsevia.  In  this  connection  it  is  interesting  to  note  that  the  average 
duration  of  the  third  stage  of  labor  in  our  premature  cases  was  23  minutes. 

HEMORRHAGE    AS    A    COMPLICATION. 

635  Cases. 

Before  Treatment.  After  Treatment. 

Early  abortions  (242) 207  cases,  85.57^  1  case. 

Late  abortions  (175) 116  cases,  66.29^  5  cases. 

Before  Delivery.        After  Delivery. 
Spontaneous  premature  labor  (218)       14  cases,    6.42^  4  cases. 


IG-A  REFORT   OF   THE   SOCIETY    OF   THE    LYING-IN    HOSPITAL. 

2.    Rtitiiiion  (if //n   IVdci-nta,  ((ml  Proloixjed  T/iird  Sf <((/<'. 

No  statements  regarding-  the  frequency  of  the  retention  of  the  ])h\eenta 
and  a  prolonged  third  stage  can  be  given,  common  complications  though 
they  are,  for  two  reasons.  The  ])atient's  statements  are  untrustworthy, 
and  are  rejected  when  she  is  seen  at  that  ])ei'iod  lirst.  Secondly,  the  thirtl 
stage  with  us  is  not  permitted  to  continue,  but  is  cut  short  by  active  meas- 
ures, such  as  ex]>ression,  manual  or  instrumental  removal  of  the  ])lacenta, 
unless  spontaneously  brought  to  a  close  within  half  an  hour. 

Perhaps  we  cannot  render  our  results  more  graphic  in  this  connection 
than  by  constructing  from  our  statistical  syno]isis  two  tables,  placing  in 
juxtaposition  the  methods  of  placental  delivery  and  the  duration  of  the 
third  stage  of  labor  in  both  late  abortions  and  spontaneous  premature 
labors.  As  we  have  already  stated,  we  have  been  able  to  recognize  a  third 
stage  of  labor  in  but  very  few  of  onr  early  abortions. 

Methods  of  Placental  Delivery  in  Late  Abortions  and  Spontaneous 

Premature  Labors. 

Late  Abortions.   Premature  Labors. 

Spontaneous  delivery 35  4s 

Expressed 19  I-IT 

Manually  removed 26  20 

Curettage  after  removal 87  6 

Ko  record 8  9 

Total m  230 


Duration  of  tue  Third  Stage   of  Labor   in  Late  Abortions  and  Spon- 
taneous Premature  Labors. 

Late  Abortions.   Premature  Labors. 

Average  duration 44  minutes.  23  minutes. 

Longest  duration 3  hrs.  45  inin.         1  hr.  30  min. 

Shortest  duration 5  minutes.  2  minutes. 

Compare  Ilajmorrhage  as  a  Complication,  and  Results  of  Treatment. 


3.  Septic  Infection.     Fever. 

Fever  as  a  Complwdtion  in  the  TJntirnely  Intel' ruption,  of  Pregnancy. — 
We  should  state  here  that  as  regards  the  limit  of  the  normal  temperature 
ante,  intra,  or  post  partum  we  liave  acce})ted  the  deluiition  of  Leopold  *'  and 
others,  who  jjhicc  this  limit  at  38  degrees  (Centigrade  or  lOO  degrees  Falu'- 
enheit,  so  that  in  the  dilTercnt  classes  of  intra  and  ])ost  partum  fever  liei-e 
studietl,  any  temjx'rature  of  100.5  degrees  l-'ahrciiheit  or  over  is  look<'<l 
upon  as  fever  and  a  pathological  condition. 

Fever  an  a  ('onijtliration  in  Karl;/  Aluirl'ionf*. — r)ur  tablcss  and  critical 
study  of  the  242  cas<*s  of  early  abortion  show  that  fever  entei-ed  into  the 


THE    PREMATURE    INTERRUPTION    OF   PREGNANCY.  165 

cases  as  a  complication  either  before  or  after  the  date  when  the  cases  were 
first  seen  by  one  of  our  physicians,  in  28  instances,  or  11. 5Y  per  cent.,  and 
tliat  in  these  28  cases  the  origin  of  the  fever  was  as  follows: 

Cases. 

Fever  due  to  sepsis 17 

"  "■      pulmonary  tuberculosis 2 

"  "      constipation 2 

"  "     pneumonia 2 

"  "     unknown  cause 5 

Total 28  or  11. 5Y^ 

Further,  that  of  these  28  cases  of  fever,  9  cases,  or  32.18  per  cent., 
w^ere  suffering  from  fever  when  first  seen;  13  cases,  or  46.57  per  cent., 
developed  fever  in  the  service  of  the  Hospital;  6  cases,  or  21.29  per  cent., 
have  no  record  of  the  temperature  w^hen  first  seen. 

Of  the  9  cases,  or  32.18  per  cent.,  suffering  from  fever  when  first  seen, 
the  fever  was  due  to : 

Cases. 

Sepsis 8 

Tuberculosis 1 

Total 9  or  32. 


Of  the  13  cases,  or  46.57  per  cent.,  that  developed  fever  in  the  service 
of  the  Hospital: 

Cases. 

Fever  due  to  sepsis 7 

"  "     tuberculosis 1 

"  "     constipation 1 

"  "     cause  unknown 4 

Total 13  or  46.57^ 

Of  the  6  cases,  or  21.29  per  cent.,  having  no  record  of  the  temperature 
when  first  seen,  subsequently  developed  fever  due  to : 

Cases. 

Sepsis 2 

Constipation 1 

Pneumonia 2 

Unknown  cause 1 

Total 6  or  21.29^ 


Fever  as  a  ComjMcation  in  Late  Abolitions. — Again  our  tables  show  that 
of  the  175  cases  of  late  abortion,  fever  appears  as  a  complication  in  38 


J6G  REPORT  OF   THE   SOCIETY   OF   THE   LYING-IN    HOSPITAL. 

iiistauces,  or  21.71  per  cent.,  ami  that  in  these  3S  cases  the  origin  of  the 
fever  was  as  follows : 

Cases. 

Fever  due  to  sepsis 27 

"■'           "     constipation 5 

"           ''     bronchitis 1 

"           ''     mastitis 1 

"           "     sepsis  and  mastitis 1 

"           "     unknown  cause '^ 

Total 38  or  21.71^ 

Further,  of  these  38  cases  of  fever,  20  cases,  or  .52.63  per  cent.,  were 
suffering  from  fever  when  first  seen;  15,  or  89.45  per  cent.,  developed  fever 
in  the  service  of  the  Hospital;  and  3,  or  7.89  per  cent.,  have  no  record  of 
the  temperature  when  first  seen. 

Of  the  20,  or  52.63  per  cent.,  suffering  from  fever  when  first  seen,  the 
fever  was  due  to: 

Cases. 

Sepsis 16 

Constipation 2 

Unknown  cause 2 

Total 20 

Of  the  15,  or  39.45  per  cent.,  that  developed  fever  in  the  service  of 

the  Hospital,  the  fever  was  due  to: 

Cases. 

Sepsis 8 

Constipation ' 3 

Bronchitis 1 

Mastitis 1 

Se])sis  and  mastitis 1 

Unknown  cause 1 

Total 15 

Of  the  3,  or  7.89  per  cent.,  that  have  no  record  of  the  temperature  when 
first  seen,  the  fever  was  due  to: 

Cases. 

Sepsis 2 

Unknown  cause I 

Total 3 

Fever  oh  a  Complication  in  Spontaneous  Premature  Lohor. — Of  the  218 
ca.sos  of  premature  labor,  our  tables  show  that  Uwv.v  entcjred  as  a  com])lica- 
tion  into  42  cases,  or  lit. 27  j)or  cent.,  and  that  in  tiiese  42  cases  the  cause 
of  the  fever  was  as  follows: 


THE    PREMATURE    INTERRUPTION    OF    PREGNANCY.  167 

Cases. 

Fever  due  to  sepsis 20 

"  "     mastitis 4 

"  "     pneumonia 3 

"  "     mastitis  and  sepsis 2 

*'  "     constipation 3 

"  "     abscess  of  breast 1 

''  "     pulmonary  tuberculosis 1 

"  "     eclampsia 1 

"  "     unknown  cause 7 

Total 42  or  19.27^ 

Further,  of  the  42  cases  of  fever,  9  cases,  or  21.42  per  cent.,  were  suffer- 
ing from  fever  when  first  seen;  31,  or  73.80  per  cent.,  developed  fever  in 
the  service  of  the  Hospital;  and  2,  or  4.76  per  cent.,  have  no  record  of  the 
temperature  when,  first  seen. 

Of  the  9,  or  21.42  per  cent.,  suffering  from  fever  when  first  seen,  the 

fever  was  due  to : 

Cases. 

Sepsis 4 

Pneumonia 2 

Unknown  cause 2 

Constipation 1 

Total 9 

Of  the  31,  or  73.80  per  cent.,  that  developed  fever  in  the  service  of  the 
Hospital,  the  fever  was  due  to : 


Cases. 

Sepsis 15 

Mastitis 4 

Sepsis  and  mastitis 2 

Constipation 2 

Phthisis 1 


Cases. 

Abscess  of  breast 1 

Eclampsia 1 

Unknown  cause 5 

Total 31 


Of  the  2,  or  4.76  per  cent.,  that  have  no  record  of  the  temperature 
when  first  seen,  the  fever  was  due  to : 

Sepsis 2  cases. 

Resume    of  Fever  as  a  Oomjplication  in   our   635   Cases  of  Untimely 
Interrupted  Pregnancy. 

Total  number  of  fever  cases  in  635  cases  of  interrupted  pregnancy,  108, 
or  17.01  per  cent. 

Total  number  with  fever  when  first  seen,  38,  or  5.98  per  cent. 

Total  number  that  developed  fever  in  the  service  of  the  Hospital,  59, 
or  9.29  per  cent. 


168 


REPORT  OF   THE   SOCIETV    OF   THE   LYING-IN   HOSPITAL. 


Total  number  septic  when  iirst  seen,  2S,  or  4.11  })er  cent. 

Total  number  that  develoi)eil  sejKsis  in  the  service  of  the  Hospital,  31, 
or  -t.  88  per  cent. 

Sepsis  is,  of  course,  the  chief  complication  of  interrupted  preg-uancy. 
Stum})f's^  cases  show  a  percentage  of  10.7  of  sepsis  in  those  expectantly 
treated,  20  ]ier  cent,  in  tliose  manually  curetted.  He  uses  the  latter  figure 
as  a  Avarning  against  the  danger  of  interference,  and  remarks  that  "  un- 
fortunately, the  hand  of  the  practitioner  in  outdoor  service  is  not  above 
reproach.""  In  spontaneous  expulsion  his  percentage  is  9.1  per  cent.;  in 
retention,  1*2.0  per  cent. — figures  wliicli  wring  from  him  the  remark  that 
the  unfortunate  sequels,  comparatively  rare  even  with  retention,  are  not 
nearly  so  frequent  as  the  advocates  of  interference  would  make  us  believe. 
In  our  242  cases  of  early  al)ortion,  IT  showed  fever  due  to  sepsis  (7  per 
cent.),  eight  of  which  had  fever  when  admitted.  In  175  late  abortions,  27, 
or  15  per  cent.,  had  symptoms  of  sepsis,  and  IG  of  them  were  infected  when 
first  seen.  Making  the  corrections,  our  percentages  of  sepsis  in  abortion 
cases  are  3.7  per  cent,  and  6.8  per  cent. ;  on  all  cases,  5.3  per  cent. 

The  gravity  of  abortion  as  a  menace  to  life  is  due  largely  to  septic 
accidents.  In  Brion's^-  530  cases,  18  deaths  are  recorded  (3.39  per  cent.). 
In  the  same  period,  in  the  same  hospital,  the  mortality  in  normal  delivery 
was  but  0.8  per  cent.  These  figures  are  not  so  eloquent  as  those  of  New 
York  City  records  from  1884  to  1894,  during  w^hich  period  the  deaths 
directly  due  to  "miscarriage"  were  equal  to  one-tenth  of  all  deatlis  from 
puer))eral  diseases  (see  ap])ended  table). 

Porak,^  in  25  cases  delivered  artificially,  had  a  mortality  of  4  per  cent. ; 
in  301  allowed  to  take  their  course,  one  died,  a  mortality  of  0.3  per  cent. 


Tai5Le  Showing  Population,  Deaths  fkom  all  Causes  in  Childhed, 
Deaths  from  Sepsis,  and  Deaths  fkom  Abortion  and  Premature 
Labor,  New  York  City  (1884-1894). 


Deaths  from 

Deaths  from 

Year. 

Estimated 

Puerperal 

Deaths  from 

Abortion  and 

Population. 

Diseases. 

Sepsis. 

Premature 

(All  Causes.) 

Labor. 

1884.... 

l,356,r,22 

438 

240 

34 

1885.... 

1,31h;.079 

:',94 

213 

40 

1886.... 

1,436,789 

371 

ist; 

37 

1887.... 

1,478,686 

355 

198 

43 

1888.... 

1,521,805 

442 

246 

41 

1889.... 

1,566,181 

3!<3 

226 

47 

1890.... 

l,<;il,K.".l 

383 

208 

45 

1891.... 

1,658,85)5 

420 

249 

48 

1892.... 

1,707,226 

417 

277 

30 

1893.... 

1,757,00!» 

384 

237 

39 

1894.... 

1,808,244 

358 

193 

47 

THE   PREMATURE    INTERRUPTION    OF    PREGNANCY.  1G9 

"Sepsis"  includes  metritis,  metroperitonitis,  pyiTemia,  septicaemia,  and 
puerperal  fever.  Abortion  and  premature  labor  ("miscarriage"  in  city 
records)  include  all  labors  before  full  term. 

Aside  from  the  question  of  sepsis,  fever  due  to  other  causes  complicates 
interrupted  ])regnancies,  as  is  to  be  expected.  It  is  a  matter  of  common 
observation  that  a  slight  chill  often  follows  curetting,  particularly  in  septic 
cases.  In  our  cases  of  early  abortion,  of  211  curetted,  8  developed  a  fever 
post  operationein^  whose  average  duration  was  three  days;  in  111  late 
abortions,  7  developed  fever  after  scraping,  Avhich  lasted  on  an  average  one 
and  a  half  days.     In  242  cases  of  early  abortion  we  find : 

Cases. 

Fever  due  to  pulmonary  tuberculosis 2 

"  "     constipation 2 

"  "     pneumonia 2 

"  "     unknown  cause 5 

In  175  late  abortions  there  was:  ^ 

Cases. 

Fever  due  to  constipation 5 

"  "     bronchitis 1 

"  "     mastitis 1 

"  "     sepsis  and  mastitis 1 

*'  "     unknown  cause 3 

Rochet's  ^^  findings  are  different.  He  says  that  the  temperature  faUs 
at  once  after  curettage,  even  in  cases  in  which  sublimate  injections  and 
iodoform  tamponade  produced  no  effect. 

tt.  Parametritis. 

Rochet^''  regards  parametritis  as  one  of  the  most  serious  complications. 
Four  of  his  39  cases  were  so  affected  when  oj)erated  on,  and  recovered 
slowly ;  one  went  on  to  suppuration.  The  curette  removed  putrid  tissue  in 
all  four.     Our  tables  shov*^  several  such  cases. 

5.   Endometritis. 

There  has  been  a  warm  controversy  as  to  the  occurrence  of  endometritis 
as  a  sequela.  Hyperplastic  endometritis  has  been  under  special  discussion. 
Schroeder  and  Yeit  ^'^^  sa}^  that  it  is  impossible  to  tell  whether  the  result  of 
a  retention  will  be  a  complete  restitutio  ad  integrum  or  a  thickened  en- 
dometrium. Goldschmidt  ^^  first  called  attention  to  the  latter  possibility. 
Ruge^^  in  eleven  cases  of  hyperplastic  endometritis,  found  a  preceding- 
abortion  in  four.  Olshausen,^*^  with  more  abundant  material,  came  to  the 
conclusion  that  an  etiological  connection  between  the  two  must  be  alto- 
gether denied.  Bischoff,^^  Brennecke,^^  Diihrssen,'^  Fritsch,^^  Henricius,^^ 
Martin, ^^  and  Kiistner,^'^  in  opposition,  lay  stress  on  such  a  connection. 
The  cases  of  Henricius  and  Iviistner  have  this  in  common,  that  there  was 
little  or  no  interference  during  abortion.  This  fact  gives  their  opinion 
weight,  since  one  of  the  chief  sources  of  error  in  examining  cases  of  en- 
dometritis is  the  reliance  which  must  be  placed  on  the  patient's  statement 
as  to  previous  occurrences.  A  decidua,  also,  firmly  adherent  to  the  uterine 
wall,  may  give  to  the  examining  finger  the  sensation  of  an  empty  uterus 


170  REPORT   OF   THE   SOCIETY    OF   THE    LVIX(t-IX    HOSPITAL, 

when  its  ]>reseiico  may  cause  an  endometritis.  Puppe^^  examined  100  cases 
with  the  idea  of  throwing  light  on  this  sul)jeet.  His  examinations  were  all 
macroscopical,  and,  consequently,  are  of  little  value,  in  spite  of  his  pains- 
taking care. 

(>.    Titini xs. 

Tetanus  has  been  reported  as  a  sequel  to  abortion.  Bennington  col- 
lected 41  cases  of  ]nierperal  tetanus,  and  of  these  two  followed  abortion. 
This  serious  complication  is  most  often  an  accident  in  tlie  course  of  a 
general  septicaemia.  We  have  no  instance  of  tetanus  to  report  among  our 
635  cases  of  interrupted  pregnancies, 

7,  l\rforaiio)i  of  ihe  Uterine  Walh. 

Perforation  of  the  uterine  walls  is  a  possible  danger  during  curettage, 
especially  if  the  sharp  instrument  be  used,  and  hence  some  authors  advise 
onlv  the  use  of  the  dull  or  blunt  instrument.*-' 

In  our  211  operations  of  instrumental  curettage  in  early  abortions,  and 
106  in  late  abortions,  or  317  altogether,  we  have  no  perforation  of  the 
uterine  wall  to  record,  and  in  most  of  these  cases  the  sharp  as  well  as  the 
dull  curette  was  used. 

As  stated  in  another  place,  these  operations  were  performed  b}^  a  large 
number  of  different  operators — one  hundred  for  these  operations  would  be 
a  low  estimate.  It  must  be  remembered,  moreover,  that  in  our  service  the 
sharp  as  well  as  the  dull  curette  is  used  in  almost  every  instance  of  curet- 
tage in  the  first  two-thirds  of  gestation. 

Our  experience  has  taught  us  tliat  the  use  of  the  blunt  curette  alone  is 
insufficient,  in  cases  of  abortion,  for  the  removal  of  the  decidua,  and  Avas 
thus  made  use  of  in  only  a  few  of  our  earlier  cases.  In  the  majority  both 
dull  and  sharp  instruments  were  used. 

The  danger  of  perforation  is  reduced  to  a  minimum  if  the  curette, 
when  introduced  into  the  uterus,  is  made  to  pass  cautiously  to  the  fundus, 
and  then  a  firm  downward  stroke  is  used  to  clear  the  uterine  walls,  espe- 
cially at  the  horns. 

8.  Mortality  in  the  635  Cases  of  the  Untimely  Inter  rxiption.  of  Pregnancy. 
Mortality  in  Early  Abortion. — We  have  to  report  among  our  24-2  early 

abortions  no  deaths  from  any  cause. 

During  the  time  tlie  Hospital  physicians  were  in  attendance  u])on  these 
cases,  none  of  thorn  were  transferred  to  other  institutions,  and,  as  far  as 
we  liavo  been  able  to  ascertain,  none  of  these  242  cases  entered  liospitals 
for  treatment  subsequent  to  our  attendance. 

As  we  show  in  anotlier  ]>lace,  the  average  duration  of  treatment  of 
the.se  early  abortions  was  seven  days  and  eight  hours.  l)y  reference  to  the 
statistical  synopsis  of  tii(,'se  cases,  it  will  Ix'  seen  \\v,\\  a,  few  cases  citlin- 
refused  tn-atment  or  called  in  ])i-iva,tc  ])liysiciaiis  or  midwives  in  the  llrst 
few  days  of  the  puer]»ci-iuiii.  and,  cons('(|Ucntly,  were  discharged  at  that 
time  from  the  service  of  the  Ilos])ital. 

\^ i'  have  endeavoi-ed,  dui-ing  a  ])erio(l  of  from  one  to  four  years  after 
the  abortions  in  our  242  cases,  to  lind  \\w.  ))atients  and  asc(!i'taiii  IVoni  tlu'in 
the  subsecjuent  histories  regarding  tiu;  lat(;  s(,'(ju(;he  of  abortion,  and  the 


THE    PREMATURE   INTERRUPTION   OF    PREGNANCY.  171 

influence  of  various  modes  of  treatment  upon  subsequent  menstruation  and 
child-bearing  (sterility). 

As  our  tables  indicate,  we  Avere  able  to  find  actually  76  of  the  total  242 
cases  and  examine  them  regarding  the  above  points  of  interest.  (See  Prog- 
nosis and  Sequela?.) 

Mortality  in  Late  Ahortions. — In  the  treatment  of  the  175  late  abortions, 
the  average  duration  of  attendance  was  seven  days  and  twenty-one  hours. 

As  in  the  case  of  early  abortions,  as  will  be  seen  by  reference  to  the 
statistical  analysis,  a  very  small  proportion  were  discharged  in  the  early 
days  of  tlie  puerperium  because  of  the  patients  refusing  treatment,  or  call- 
ing in  private  ])hvsicians  or  midwives. 

We  have  one  death  to  report  among  the  175  late  abortions.  The  fol- 
lowing is  an  abstract  of  the  case: 

C.  ]Sr.  1,198. — Russian;  age  36;  YI.  para;  sixth  month  of  gestation; 
no  record  of  previous  interrupted  pregnancies ;  s3aiiptoms  of  hasmorrhage 
had  continued  twelve  hours  when  first  seen  by  the  Hospital  physician; 
before  being  seen  by  the  latter,  two  private  physicians  in  attendance ;  pla- 
centa prcevia;  severe  antepartum  hgemorrliage ;  dilatation  with  Barnes's 
bags;  rupture  of  the  uterus;  jDodalic  version;  still-born  child;  placenta 
manually  extracted  by  the  Hospital  physician;  duration  of  the  third  stage, 
five  minutes;  death,  thirty-six  hours  postpartum,  of  shock. 

Five  of  the  175  cases  of  late  abortion  were  for  various  reasons  trans- 
ferred to  some  other  hospital  at  different  periods  of  the  puerperium.  Two 
of  these  were  homeless  and  friendless;  one  was  suffering  from  chronic 
pulmonary  tuberculosis;  one  from  chronic  pulmonary  tuberculosis  and 
endocarditis;  one  from  endocarditis,  and  one  from  parametritis.  We 
append  abstracts  of  these  cases. 

1.  C.  ]Sr.  1,1:68. — Russian;  age  36 ;  Y.  para;  fifth  month  of  gestation; 
child  born  before  arrival  of  Hospital  official ;  symptoms  had  continued  two 
days  when  the  patient  was  first  seen ;  child  still-born ;  placenta  broken  u-p 
in  delivery;  antepartum  haemorrhage;  instrumental  curettage  and  intra- 
uterine douche;  no  fever;  patient  transferred  to  Gouverneur  Hospital 
March  3,  1892.  ISTo  record  of  the  patient  can  be  found  on  the  hospital 
books ;  she  entered  the  institution  under  an  assumed  name. 

2.  C.  jST.  1,785. — Roumanian;  age  21;  III.  para;  fourth  month  of  ges- 
tation; unattended  by  Hospital  official;  symptoms  had  continued  one  day 
when  seen ;  child  still-born ;  placenta  broken  up ;  antepartum  haemorrhage 
moderate;  temperature  103  degrees  Fahrenheit  when  seen;  103  degrees 
Fahrenheit  after  o]3eration ;  digital  and  instrumental  curettage;  transferred 
to  Gouverneur  Hospital  on  the  second  day  of  the  puerperium  with  symp- 
toms of  parametritis;  records  at  Gouverneur  Hospital  state  that  the  patient 
was  treated  there  three  days  for  ' '  pelvic  cellulitis ' '  and  discharged 
"cured." 

3.  C.  ]^.  3,985.- — Russian;  age  19;  I.  ^^ara;  fifth  month  of  gestation; 
unattended  by  Hospital  official;  symptoms  of  haemorrhage  had  continued 
twelve  hours  when  first  seen;  child  still-born ;  placenta  spontaneously  deliv- 
ered; membranes  intact;    vaginal  douche  the  only  treatment;  no  fever; 


IT'2  REPORT   OF  THE   SOCIETY   OF  THE   LYIN(?-IX    HOSPITAL. 

homeless  ami  I'rieiuUess ;   went   to  some  hospital  on  the  third  day  of  the 
piierperiiim ;  unable  to  trace  the  patient. 

4.  C.  X.  5,215>. — Russian;  age  21;  I.  para;  fourth  month  of  gestation ; 
attended  by  the  lIos|)ital  official;  child  still-born;  placenta  broken  up; 
moderate  antepartum  haemorrhage;  temperature  100. G  degrees  when  first 
seen;  highest  temperature,  100. C  degrees;  first  day,  day  of  highest  tem- 
perature; total  duration  of  fever,  a  few  hours;  operation  at  once;  instru- 
mental cui-ettage.  uterine  douche;  fever  due  to  sepsis;  discharged  seventh 
day  in  poor  condition;  seen  two  weeks  later  with  parametritis;  sent  to 
Gouverneur  Hospital  December  IT.  1S03;  discharged  from  that  hospital 
December  31,  lS!t3,  sutfering  from  inild  endometritis. 

5.  C.  X.  7,070. — American;  age  30;  V.  para;  third  and  a  half  month 
of  gestation;  symptoms  present  four  days  when  seen;  ])lacenta  broken  uj); 
moderate  antepartum  luemorrhage;  six  hours  between  first  visit  and  o])er- 
ation;  temperature  lol.2  degrees  Fahrenheit  when  first  seen,  101.2  degrees 
after  o})eration,  102.8  degrees  on  second  day;  fever  lasted  fourteen  days; 
instrumental  curettage  and  uterine  douche;  discharged  fifteenth  day  in  bad 
condition,  to  be  transferred  to  St.  Francis  Hospital;  sepsis  and  pericarditis. 
The  patient  entered  the  hos]iital  under  another  name  and  was  lost  sight  of. 

Jforttdiii/  in  Spontaneous  P/'eniaturc  Labors. 

Among  the  175  spontaneous  premature  labors  there  were  four  deaths. 
Tliree  of  these  occurred  in  the  service  of  our  Hos]iital,  and  the  causes  of 
death  were  (1)  shock  and  liEemorrhage  from  a  placenta  praevia,  (2)  broncho- 
pneumonia, and  (3)  eclampsia.  Another  patient  died  on  the  second  day  of 
the  puerperium,  twenty-four  hours  after  the  case  had  been  turned  over 
to  a  private  ]:)hysician. 

AVe  have  thus  three  deaths  among  the  175  cases  in  owy  owii  service, 
and  four  if  we  include  the  case  which  subsequently  terminated  fatally. 

As  far  as  we  have  been  aljle  to  trace  our  cases  after  their  confinements, 
the  above  include  all  the  fatal  cases. 

Six  other  cases  were  transferred,  for  various  reasons,  to  other  institu- 
tions, and  as  far  as  we  have  been  able  to  follow  these  six  cases  there  were 
no  fatal  terminations. 

The  following  is  a  synopsis  of  the  four  cases  in  which  death  followed 
a  s})ontaneous  premature  delivery: 

1.  (.'.  X.  340.  —  Dutcli;  age  31;  11.  para;  ninth  and  a  lialf  month  of 
gestation;  conlincd  \\\  the  Hospital  official;  iirst  seen  in  the  first  stage  of 
labor;  child  lived  thr(!e  days;  phicenta  ])ran'ia;  podalic  version;  manual 
extraction  of  tlic;  ])lacenta;  third  stage  lasted  thirty-Jive  minutes;  death  on 
third  day  of  ha-morrhage  and  slKx-k. 

2.  CJ.  X.  I.72;5. — American;  age3S;  VI.  ])ara;  uinth  and  a  half  montli 
of  ge.station;  conlin(!(l  by  the  Hospital  olHcial;  iirst  se(;n  in  the  Iirst  stage 
of  labor;  child  lived  two  days;  placenta  ex])ressed;  tliiid  stage  lasted 
thirty  minut(!s;  prola))S(!  of  hand;  no  record  of  Uwo.r  wli(;n  seen;  later  teni- 
pemture  1O0.2  degrees;  death  on  seventh  (hiy,  of  broncho-i)neumonia. 

3.  C.  N.  6,925, — American;  age  31 ;  VIII.  ])ara;  ninth  month  of  gesta- 
tion ;  two  previous  premature  laboi-s:  unatlcndcd  by  Hospital  official ;  still- 


thp:  prematl:re  ixtkrruptiox  of  pregnancy.  173 

born  child;  placenta  expressed;  third  stage  lasted  thirty  minutes;  albumi- 
nuria; [)rivate  physician  took  charge  of  case  on  first  day  of  the  puerperium ; 
it  was  learned  that  the  patient  died  twenty-four  hours  later,  of  nephritis. 

4.  C.  K.  7,070. — Russian;  age  26;  II.  para;  ninth  and  a  half  month 
of  gestation;  confined  by  the  Hospital  official;  first  seen  in  first  stage  of 
labor;  child  lived  only  a  few  minutes;  placenta  expressed;  third  stage 
lasted  five  minutes ;  eclampsia ;  manual  dilatation  and  incision  of  the  cervix ; 
podalic  version  and  extraction;  death  from  eclampsia,  on  second  day. 

Six  of  our  cases  of  spontaneous  premature  delivery  were,  for  various 
reasons,  transferred  to  some  other  hospital.  One  was  delivered  of  a  ma- 
cerated foetus  while  undergoing  the  usual  antepartum  examination  in  the 
present  sub-station  building  of  the  Hospital;  she  was  homeless  and  friend- 
less. The  remaining  five  were  transferred  to  other  institutions  because  it 
was  judged  that  their  condition  demanded  routine  hospital  treatment  which 
could  not  be  properly  carried  out  in  the  tenement  houses.  We  append  below 
an  abstract  of  these  six  cases: 

1.  C.  IS".  150. — German;  age  30;  I.  para;  ninth  month  of  gestation; 
child  lived  one  day;  profuse  postpartum  hemorrhage;  temperature  101.2 
degrees  when  first  seen;  highest  temperature  101.2  degrees,  on  second  day; 
fever  lasted  thirty  days;  instrumental  curettage;  sepsis;  sent  to  Bellevue 
Hospital  on  twenty-eighth  day  of  puerperium;  there  she  remained  three 
weeks,  and  was  discharged  entirely  cured. 

2.  C.  K.  189. — American;  age  22;  II.  para;  seventh  month  of  gesta- 
tion; one  previous  abortion;  confined  by  Hospital  official;  first  seen  in 
first  stage  of  labor ;  child  lived  five  hours ;  placenta  spontaneously  deliv- 
ered ;  antepartum  hgemorrhage ;  albuminuria ;  discharged  on  eleventh  day 
in  bad  condition  and  transferred  to  Bellevue  Hospital. 

3.  C.  ]^.  657. — Russian;  age  23;  Y.  para;  eighth  month  of  gestation; 
confined  by  Hospital  official;  first  seen  in  first  stage  of  labor;  child  lived 
three  days;  placenta  expressed;  third  stage  lasted  five  minutes;  highest 
temperature  101.3  degrees,  on  third  day;  duration  of  fever  a  few  hours; 
albuminuria;  mastitis;  extreme  oedema  and  ascites  at  labor;  discharged 
on  tenth  day  in  bad  condition;  transferred  to  Belleviie  Hospital,  where  the 
patient  remained  only  a  few  days. 

4.  C.  jST.  3,690. — American;  age  27;  II.  para;  eighth  month  of  gesta- 
tion ;  confined  by  Hospital  official ;  first  seen  in  second  stage ;  macerated 
child;  placenta  expressed;  third  stage  lasted  twenty  minutes;  no  fever; 
confined  on  examining  table  of  the  Hospital;  transferred  immediately  to 
Gouverneur  Hospital,  which  she  entered  March  24, 1893,  and  was  discharged 
March  28,  1893,  in  good  condition. 

5.  C.  ]Sr.  5,945. — Russian;  age  25;  III.  para;  seventh  month  of  gesta- 
tion; one  previous  premature  labor;  confined  by  Hospital  official;  first 
seen  in  second  stage ;  child  lived  one  day ;  placenta  spontaneously  deliv- 
ered; duration  of  third  stage  ten  minutes;  temperature  103  degrees  on 
third  day.  Fever;  pulmonary  tuberculosis;  discharged  on  ninth  day  in 
bad  condition;  sent  to  Gouverneur  Hospital  April  17,  1894.  Patient  can- 
not be  traced,  as  she  entered  under  an  assumed  name. 


IT-i  REPORT   OF   THE   SOCIETY    OF   THE    LYlXtMN   HOSPITAL. 

G.  C.  N.  0,128, — Russian;  age  20;  I.  ))ara;  ninth  niontli  of  gestation; 
confined  bv  lIos})ital  official;  tirst  seen  in  first  stage;  child  lived  one  day; 
placenta  expresseil;  third  stage  lasted  fifteen  minutes;  temperature  104 
degrees  when  first  seen ;  treated  for  two  Aveeks  jirior  to  hibor  by  ])rivate 
])h\sician  for  fever,  heatlaclie,  and  diarrha?a  (typhoid);  transferred  to  ])elle- 
vue  Hospital  on  the  third  day  of  the  puerperium.  Admitted  to  Bellevue 
Mav  0, 1804 ;  treated  there  for  tv])hoid  fever ;  discharged  cured,  IMay  30,  1894. 

Bti<i(iii('  of  t/ie  Moi'taliti/  hi  o(ir  (335  Cases  of  Untimely  Interrupted 
J^regnanci/. 

^fortality  in  242  cases  of  early  abortion,  0  per  cent, 

M(.)rtality  in  17.")  cases  of  late  abortion,  one  case,  or  0.57  per  cent.  Cause 
of  death  was  placenta  ])riT3via  and  ru})ture  of  the  uterus. 

Mortalitv  in  218  cases  of  spontaneous  ])remature  labor,  three  cases,  or 
1.37  per  cent.  Causes  of  death  were  (1)  placenta  pnevia,  haemorrhage, 
and  shock;  (2)  broncho-pneumonia;  (3)  eclampsia. 

Total  Mortality  in  the  635  Cases  of  Interrupted  Pregnancy,  ().^?>2>er  cent. 

Summing  up,  Ave  find  as  sequels  or  complications  of  interrupted  preg- 
nancy, first,  and  most  important,  sepsis  in  all  its  forms — metritis,  parame- 
tritis, endometritis,  septicaemia,  pyaemia,  fever;  intercurrent  disease  giving 
rise  to  fever,  e.g.,  tuberculosis,  retention  of  placenta  and  decidua  Avith  con- 
sequent hyperplastic  endometritis,  subinvolution,  etc. ;  haemorrhage  leading 
often  to  sepsis;  tetanus;  death  as  a  result  of  one  or  more  of  these  compli- 
cations. 

Prognosis,  according  to  Lepage,'*'"  varies  according  to: 

(1)  The  period  of  gestation,  the  danger  of  being  less  toward  the  third 
or  fourth  month. 

(2)  Retention  of  placenta  and  membranes. 

(3)  Treatment. 

All  these  may  be  condensed  into  one  Avord,  treatment  /  and  Ave  have 
altogether  failed  in  this  laborious  undertaking  if  Ave  have  not  made  clear 
and  unmistakable  our  interpretation  of  the  meaning  of  that  Avord. 

Skquel;e. 

1.  Sterility. 

Oldhausen's  school,  Stumpf^  s^ivs,  in  particular,  deserves  what  credit 
there  is  in  having  "  reduced  to  their  ])roper  level  the  fears  of  the  evil 
results  to  be  anticipated  from  the  retenti(m  of  membranes"  in  premature 
\:\\)()v.  Winter""  says  the  puerperium  is  not  disturbed  by  retention,  and 
the  inucous  membrane  regains  its  functional  activity  in  a  short  time. 
His  point  of  vi(;w  is  purely  clinical.  In  ;{s  ])er  cent,  of  his  cases  Avitli 
partial  or  com})lete  retention,  pregnancy  ensued  early,  while  after  re- 
moval of  the  v(!ra,  conception  occurred  in  ('>.2!>  per  cent.  only.  Ru])])(;,"*' 
Avho  publislied  thes(;  results,  conclud(!s  from  tlies(;  ligui-es  that  a  uterine 
irnu'ous  memy>rane  completely  renewed  after  abortion  is  less  capable  of 
jdaying  the  j)art  of  a  (hscidua  of  ])regnam-y  than  own  Aviiich  lias  <l(jne  so 
before  in  whole  or  in  |)art.  One  hun(h-ed  cases  Avere  carefully  kept  un<l(M- 
observation  by  him  before,  during,  and  for  some  time  after  abortion.     The 


THE    I'HEMATURE    INTERRUPTION    OF    PREGNANCY. 


175 


menses  returned  usually  in  four  weeks  in.  all  cases.  Puppe  carefully  se])a- 
rated  the  healthy  women  from  those  previously  diseased,  but  it  does  not 
a))pear  that  he  had  seen  the  fruit  of  conception  when  it  occurred.  In 
other  words,  he  does  not  state  tluit  the  child  was  carried  to  term.  More- 
over, he  divides  his  cases  into  two  groujjs:  (1)  cases  running  their  course 
with  retention,  and  (2)  those  in  which  the  entire  vera  was  removed,  and 
draws  his  conclusions  when  he  confesses  himself  unable  to  state  that  the 
removal  is  ever  complete.  Durlius,  on  the  other  hand,  mentions  sixty 
cases  of  conception  following  curettage. 

Certainly,  our  figures  lead  one  to  a  far  different  conclusion  from  Pup- 
pets. Of  119  cases  treated  instrumentally,  38,  or  31.9  per  cent.,  had  expe- 
rienced one  or  more  previous  interrupted  pregnancies;  5,  or  4,2  per  cent., 
suffered  subsequently  in  the  same  way;  48,  or  40.3  per  cent.,  gave  birth  to 
living  children  at  term;  and  21,  or  17.6  per  cent.,  were  found  to  be  preg- 
nant from  the  fourth  to  the  eighth  month  when  visited.  These  observa- 
tions were  made  at  the  patients''  koines  and  the  children  seen.  Of  28  cases 
of  abortion  expectantly  treated,  10,  or  35.7  per  cent.,  had  had  similar  pre- 
vious experiences.  Wone  suffered  from  subsequent  interrupted  pregnan- 
cies; 7  gave  birth  to  living  children  at  term  afterward  (25  per  cent.);  5,  or 
17.8  per  cent.,  were  found  to  be  pregnant  from  the  fourth  to  the  eighth 
month  when  visited.  It  is  interesting  to  tabulate  these  results  for  com- 
parison, in  spite  of  the  disparity  in  the  number  of  cases.  (It  should  be 
borne  in  mind  that  these  women  were  found  with  great  difficulty,  thus 
accounting  for  the  comparatively  small  number  of  returns.) 


Treatment. 

Subsequent 
Interrupted 
Pregnancy. 

Full-term 
Pregnancy. 

Pregnant 

4th  to  8th 

Month. 

Expectant  cases 

0.0^ 

4.2^ 

25.0^ 
40.3^ 

17.8^ 

Instrumental  cases 

17.6^ 

(See  Tables  of  Results  in  Early  and  Late  Abortions.) 

The  points  in  which  the  instrumental  treatment  suffers  by  comparison 
is  in  the  percentage  of  subsequent  interrupted  pregnancies,  and  also  in  the 
fact  that  31.9  per  cent,  of  the  instrumental  as  against  35.7  per  cent,  of 
expectant  cases  had  previously  aborted.  One  case  digitally  curetted  gave 
birth  to  two  children  afterward. 

Diihrssen  ^^  believes  that  the  retention  of  a  part  of  the  decidua  is  the 
rule,  and  that  this  retention  is  ominous,  on  account  of  hsemorrhage  or 
sepsis,  Stumpf  ^  denied  this  assertion,  says  it  cannot  be  proved  clinically  or 
anatomically,  and  claims  that  it  is  disproved  by  the  observations  of  Winter  ^°^ 
and  Puppe, ^^  and  also  by  Klein, ^•'^  who  concludes  from  his  studies  on  involu- 
tion that  the  vera  is  transformed  in  loco  to  mucous  membrane  in  from 
four  to  six  weeks.  We  refer  the  reader  to  the  section  on  Pathology  for  a 
demonstration  of  the  fact  that  Diihrssen  is  correct  in  the  stand  he  takes. 


170  REPORT   OF   THK   SOCIETY    OF   THE    LYIXG-IN   HOSPITAL. 

2.   En<1om€ti'iU'^  un<l  Ojh I'at ire  Intei'feri'iwe. 

As  regards  endometritis,  diametrically  op])osite  opinions  are  again 
maintained.  Stnm]it',  Winter,  and  Pnppe  say  that  it  is  not  the  result  of 
aboi-tion  and  retention  of  membranes,  and  point  to  Yeifs '"'  curetted  cases, 
in  which  the  endometritis  had  to  be  treated  after  the  puerperium  was 
ended.  They  neglect  to  suggest  the  possibility  of  a  ])rior  abortion  exjDec- 
tantly  treated  being  at  the  bottom  of  the  trouble.  Reference  to  the  table 
given  above  (^]xige  175)  shows  a  15.3  greater  percentage  of  subsequent  preg- 
nancies when  the  secundines  were  instrumentally  removed,  which  is  toler- 
ably fair  evidence,  at  least,  that  these  cases  were  free  from  endometritis. 

We  also  attempted  to  learn  and  compare  the  character  and  duration  of 
the  lochial  discharge,  the  character,  time,  and  duration  of  the  first  men- 
struation following  the  al)ortion,  in  cases  allowed  to  run  their  course  with 
retention  of  the  vera  (expectant  treatment),  and  in  those  in  Avhich  the 
entire  vera  was  removed  at  the  time  of  the  abortion  (curettage). 

Our  ()l)servations  in  the  1-1-8  cases  of  abortions  (70  early  and  72  late) 
were  mainly  dependent  upon  the  statements  of  the  ]:)atients,  and  for  this 
reason  we  have  considered  them  too  doubtful  and  unreliable  to  use,  and 
have  consequently  abandoned  them  as  useless.  On  the  other  hand,  as 
alreadv  stated,  our  observations  \\\>o\\  the  subsequent  labors  at  term  and 
subsequent  pregnancies  are  exact,  because,  in  each  of  the  148  cases  reported 
upon,  the  women  and  tlieir  cliildren  were  seen. 

AVe  ajjjjend  in  the  foot-note  Fuppe's  observations.* 

*G.  PuppE  :  Inaugural  Dissertation,  Berlin,  1890. 

Turning  now  to  the  real  object  of  the  examiiiatioii,  namely,  the  consideration  of 
the  sequela?  after  abortion,  we  shall  find  that  the  material  before  us  can  be  readily 
divided  into  two  groups  corresponding  to  the  starting  point  of  the  investigations :  (1) 
cases  running  their  course  ivith  retention  of  the  vera ;  (2)  those  in  which  the  entire 
vera  zras  rentoi'ed  dnring  the  abortion.  Regarding  the  course  of  the  abortion,  the 
latter  group  is  again  divisible  into  those  cases  in  wiiich  tlie  entii'e  ovum  was  sponta- 
neou.sly  e.xpelled,  and  those  in  wliich  the  removal  of  the  entire  vera  required  inter- 
ference, though  it  be  only  a  manual  one. 

Of  the  100  cases  here  under  consideration,  ten  belong  to  the  first  group,  those 
whicli  have  run  their  course  without  any  medical  interference  ;  but  of  these  we  must 
exclude  the  lai-ger  half  (seven),  l^ecause  they  complained  before  the  abortion  of  symp- 
toms wliich  rend(!red  disease  of  the  uterus  almost  certain  (cliiefly  endometritis).  The 
exclusion  is  the  more  obvious,  as  our  main  object  is  to  study  the  sequekc  of  abortion 
in  healthy  women.  For  the  same  reason  it  is  absolutely  necessai'y  to  make  a  like 
separation  in  the  other  groups  made  in  this  treatise.  A  separate  section  will  b(^ 
devoUid  to  tin;  .seriuehe  after  abortion  in  uimirii  pi-eviously  di.seased. 

In  jr'''"'ral  tln^  ova  d(!rivc'd  from  tliis  entire  grouj),  six  of  which  Avere  of  the  thii'd 
montli  and  four  of  tin;  sfrcond,  W(;ri!  nearly  tln-onghout  fine  specimens,  as  I  must  not 
fail  to  empluusize  here.  Tlie  ovisacs  were  intact,  frequently  with  recently  dead,  rarely 
with  partly  al>s<jrlx;d,  f(jetu.sex  ;  the  chorion  was.  as  a  rule,  surrounded  with  tlie  un- 
injured rertexa  ;  the  dtn^idua,  as  is  self-evid<;nt  from  the  age  of  the  ova,  not  adherent 
togetber.  the  transition  folds  cle;irly  jironounccul.  As  stated  aliove,  treatnuMit  in  all 
tbes<;  viisf^  IkkI  l)e«'n  made  unnecessary  by  tli(^  spontaneous  course  ;  by  tlie  time  the 
|K)lyr-]inifal  ;ittendant  rejioln-d  tin;  bedside  tlie  ova  weri'  in  part  delivered  into  tlie 
vagina,  wben  tlie  internal  os  Wiis  always  found  closed;  in  jiart  they  were  handed  to 
the  attendant  on  his  arrival,  iis  alnmdy  fully  delivered. 


THE    PREMATURE   INTERRUPTION   OF    PREGNANCY.  177 

The  several  points  to  which  the  later  examination  had  to  be  directed  are  the  state 
of  the  lochial  discharge,  tlie  condition  of  the  first  and  the  subsequent  menses.  First, 
as  regards  the  lochial  discharge,  it  lasted  in  two  of  the  cases  eight  days,  in  the  third 
the  length  of  time  is  given  as  six  weeks,  up  to  the  time  of  the  first  menses.  The 
former  two  statements  appear  normal,  but  the  latter  surprised  us,  all  the  more  because 
the  further  symptoms  in  this  patient  (even  conception  occurring  after  five  recurrences 
of  a  normal  menstruation)  pointed  to  a  healthy  condition  of  the  uterus.  An  explana- 
tion of  the  fact  niight  perhaps  be  found  in  the  normal  mode  of  detachment  of  the 
decidua  vera  from  the  uterine  wall  as  descril^ed  by  Diihrsseu.  According  to  this 
observer  the  region  of  separation  of  the  vera  is  not  in  its  sui^erficial,  but  in  the  deeper 
ampullary  glandular  layer.  If  we  assume  in  our  case  a  separation  at  first  only  in  the 
superficial  region,  then  it  was  the  object  of  the  lochial  discharge  to  complete  it ;  that 
is  to  say,  to  eliminate  the  decidual  elements  as  far  as  the  deeper  layer — a  task  which 
could  not  be  completed  within  the  normal  duration  of  the  lochia.  Whether  this 
explanation  is  true  cannot  be  ascertained,  since  no  microscopical  examination  was 
made  of  the  expelled  vera ;  at  any  rate  it  is  probable. 

As  stated  before,  in  this  case  the  first  menses  occurred  after  the  termination  of 
the  lochia,  i.e.,  in  six  weeks  ;  in  the  other  two  cases,  after  five  and  four  weeks 
respectively  ;  in  all  cases  it  was  rather  profuse  without  being  painful,  lasting  three  to 
five  daj^s.  The  i^rofuseness  of  the  first  catamenia  is  counterbalanced  by  the  relative 
scantiness  of  the  next,  a  fact  positively  asserted  by  all  the  three  patients.  The  suc- 
cession of  the  several  menstruations  was  in  two  cases  regular,  at  four  weeks'  interval 
(in  one,  see  above,  conception  soon  occurred)  ;  in  the  third  case,  which  was  compli- 
cated with  chlorosis,  it  was  irregular,  the  interval  being  once  five  weeks,  several  times 
three  weeks. 

Next  to  this  group  of  cases  with  spontaneous  course  comes  another  which  was 
terminated  manually  only,  in  which  the  entire  vera  was  removed  from  the  uterus. 
The  number  of  cases  belonging  under  this  head  is  14  ;  again  we  must  exclude  8  cases 
as  diseased  previous  to  the  abortion.  Of  the  remaining  6  cases,  2  were  of  the  second, 
3  of  the  third,  and  1  of  the  fourth  month.  In  these  cases  the  lochial  discharge  was 
absolutely  noi-mal  ;  as  a  rule  it  lasted  eight  days,  only  once  the  duration  is  given,  as 
in  the  former  group,  until  the  first  catamenia.  The  first  menses  occurred  four  times 
after  four,  once  after  five,  and  once  after  six  weeks  ;  in  the  great  majority  it  was 
profuse  and  normal  in  duration.  The  further  course  of  the  menses  was  also  normal ; 
four  Aveeks  are  uniformly  stated  as  the  interval.  No  conception  is  to  be  noted  in  this 
group. 

In  endeavoring  to  draw  a  conclusion  from  all  these  abortions  unquestionably 
terminated  by  the  expulsion  of  the  entire  vera,  we  are  struck  in  the  first  place  by  the 
large  number  of  sick  patients  (15)  in  comparison  with  those  not  sick  (9) ;  all  the  more 
because  in  every  case  the  vera  was  detached  spontaneously  or  by  a  purely  manual 
interference  (hence  without  any  great  difficulty) .  In  the  majority  of  cases  the  deciduae 
are  marked  in  my  list  as  "  thickened."  If  they  form,  as  the  history  shows  beyond  a 
doubt,  the  main  constituent  of  an  inflamed  endometrium,  the  fact  here  observed 
deserved  mention  in  view  of  the  circumstance  also  noted  by  Veit,  among  others, 
' '  that  when  it  undergoes  inflammatory  thickening  it  becomes  more  firmly  adherent 
to  the  uterus."  The  large  proportion  of  the  sick  to  the  well  (5  to  3),  in  all  of  whom 
the  vera  was  detached  spontaneously  or  with  slight  exertion,  is,  at  all  events,  very 
remarkable. 

The  period  of  involution  was  apparently  normal  in  all  cases  ;  the  duration  of 
the  lochia,  its  quality,  the  absence  of  haemorrhages,  and  the  later  well-being  of  the 
patients  indicate  it.  The  first-named  period  is  almost  uniformly  given  as  eight  days ; 
the  two  statements,  which  differ,  can  probably  be  sufficiently  explained  :  the  quality 
of  the  lochia  corresponds  to  the  symptoms  known  from  the  puerperium,  but  the  bloody 
lochia  here  seem  to  be  of  much  slighter  importance.  The  statements  made  to  me  are, 
as,  a  rule,  that  the  lochial  discharge  had  been  at  first  bloody,  had  gradually  become 
12 


ITS  REPORT   OF   THE   SOCIETY   OF   THE    LYING-IN    HOSPITAL. 

lighter,  and  tinally  \vhiti;sh.  Putrescence  was  denied  in  all  cases  ;  only  a  stale  odor 
was  admittetl.  The  quantity,  too,  was  almost  regularly  slight  ;  the  question  whether 
haMuorrhages  had  taken  i)lace,  or  coagula  passed,  was  always  denied. 

The  condition  of  the  liist  menstruation  is  remarkable  in  so  far  as  all  the  women 
called  it  profuse.  That  tliis  statement  is  correct  can  hardly  be  doubted,  although 
occasionally  the  statements  of  a  single  person  are  not  always  as  reliable  as  might  be 
desii-ed.  despite  the  most  careful  questioning ;  yet  when  the  reports  are  almost  unani- 
mous, doubt  would  scarcely  be  in  place.  Still  the  fact  per  se  is  remarkable  enough. 
When  imder  other  conditions  the  genitals  are  subject  to  periodical  engoi'gements  of 
blood  which  hiul  expression  in  menstruation,  it  seems  strange  that,  after  tlie  genitals 
have  just  discharged  a  considerable  quantity  of  blood,  a  profuse  menstrual  luomorrhage 
again  occui"s  in  four  to  at  most  six  weeks.  This  phenomenon,  however,  finds  its  ana- 
logue in  the  profuseness  of  the  first  eatamenia  usually  observed  after  delivery. 

The  time  of  the  return  of  the  first  menses  was  in  the  majority  of  oases  (5)  four 
weeks  ;  in  2.  five  weeks  :  and  in  2,  six  Aveeks.  The  duration  of  the  courses  ranged 
between  three  and  eight  days  ;  they  were  never  painful. 

Regarding  the  .srco»(Z  and  the  later  )neiises,  the  fitateinents  obtained  are  normal  ; 
a  type  of  four  weeks  exists  throughout,  with  relative  scantiness — a  fact  which  deserved 
to  be  specially  emphasized  in  view  of  the  profuseness  of  the  preceding  one.  The 
above-described  single  instance  of  conception  occurring  appears  unsuitable  for  making 
remarks  about  the  regaining  of  the  power  of  conception  in  this  connection.  A  better 
opportunity  will  ])resent  hereafter. 

Next  in  order  after  the  abortions  terminated  by  the  positive  removal  of  the  entire 
vera,  it  will  be  best  to  consider  the  group  treated  with  the  curette.  In  these  cases, 
likewise,  we  might  a.ssert  that  the  entire  vera  was  removed  by  the  curette,  since  this 
was  the  object  of  the  interference  ;  but  I  prefer  to  treat  of  the  curetted  cases  in  a  group 
by  themselves.  My  motive  in  making  this  separation  was  this  :  I  have  above  ex- 
pres.sed  my  intention  to  separate  the  availal^le  cases  into  those  of  total  removal  of  the 
vera,  and  total  or  partial  retention  of  the  vera,  since  what  was  handed  to  me  as  actu- 
ally expelled  was  a  voucher  for  the  correctness  of  the  relations  named.  In  the  cases 
treated  by  curettage,  however,  it  is  a  different  matter.  While  it  is  most  probable  that 
the  thorough  use  of  the  curette  has  removed  all  of  the  v^era,  we  cannot  be  quite  sure 
that  a  smaller  or  larger  piece  of  vera  was  not  left  adherent  somewhere. 

For  the  rea-son  stated,  we  cannot  assign  tlie  same  reliability  to  the  conclusions 
drawn  from  the  sequehe  after  abortion  in  tliis  group  as  in  the  remaining  cases  ;  but  I 
may  re.strict  my.self  to  the  enumeration  of  tiie  most  important  points  for  this  group. 
First,  a.s  regards  the  indication  for  the  curettage  in  these  cases,  it  may  be  said  that  it 
wa.s  found  mainly  in  the  presence  of  very  firmly  adherent  shreds  of  vera  which 
resisted  manual  treatment. 

Tlie  inunber  of  curetted  cases  was  14,  from  wliich  we  must  exclude  7  as  pi'eviously 
di.seased.  Tiie  remaining  7  differed  from  the  former  by  a  rather  long  duration  of  the 
lochial  di.scharge  in  tlie  majority  of  ca.ses.  In  2  the  lochia  continued  until  the  iir.st 
men.struation  after  the  abortion,  and  in  2  others  they  lasted  two  weeks.  This  fact 
might  lend  color  to  the  above-mentioned  po.ssibility  that  the  curette  had  left  ample 
cause  for  tlie  activity  of  tlie  lochia.  Two  mor<!  pati(Mits  state  the  duration  of  the  lochia 
a.s  ten  and  eight  days  res{)ectively  ;  tin;  seventh  claims  not  to  have  noticed  tliem  at 
all.  The  quahty  of  the  liK-hia  was  normal  throughout ;  the  passage  of  coagula,  por- 
tions of  the  decidua,  or  perhaps  a  lucmorrhage,  luul  never  been  observed. 

All  wom^n  menstruated  first  four  weeks  after  abortion,  and  they  too  unanimously 
reported  that  the  men.ses  were  profu.se  ;  the  duration  ra!ig(^d  between  two  and  eight 
days.  According  t*)  the  patients  they  wen;  uiiifornily  i)ainle.ss.  The  subseqiuMit  eata- 
menia api>eare<l  in  all  women  afUsr  four  weeks'  int»!i'val,  a Ivv^ays  scantier  than  the  first, 
but  normal.  ( 'onception  had  not  occurred  in  any  of  the  jiatients  at  the;  time  of  the 
l-'LHt  <'xamination. 


THE    PREMATURE    INTERRUPTION    OF    FREGXANCY. 


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THE    PREMATURE    INTERRUPTION    OF   PREGNANCY.  183 


Treatment. 

Turning  to  the  treatment  of  sucli  cases  as  form  the  subject  of  this  paper, 
it  is  well  to  review  other  Avork  in  the  same  line  and  to  show  how  weight 
of  opinion,  notably  German,  turns  the  balance  in  favor  of  the  active  treat- 
ment we  advocate.  Curettage  is  not  new.  Eecamier  used  it  in  Austria 
in  1846;  Boetus^"^  advocated  it  in  187T.  Opinions  differ  widely,  as  might 
be  ex^^ected,  not  only  as  regards  indications  for  and  the  method  of  using  it, 
but  as  to  its  expediency  in  any  case.  Czobos  ^°'  advised  expectant  treat- 
ment alone,  setting  aside  the  curette  on  the  ground  that  active  interference 
is  apt  to  produce  septic  absorption.  His  preference  is  for  the  tampon 
and  ergotin.  E.  Schwarz^*^^  uses  manual  dilatation  and  curetting  if  the 
ovum  is  intact,  instrumental  procedure  in  case  it  is  not.  From  these  opin- 
ions it  is  possible  to  pass  by  easy  stages  to  the  radical  and  uncompromising 
stand  of  Weekbecker-Sternfeld  ^*''  and  Duhrssen,^°^  who  condemn  temporiz- 
ing in  any  form.     The  latter  is  our  position  also. 

All  methods  for  the  management  of  abortion  may  be  systematically 
classified  as  follows: 

1.  Purely  conservative  or  expectant  treatment.  Interference  is  alto- 
gether interdicted,  and  the  sole  reliance  placed  upon  the  tampon,  vaginal 
irrigation,  and  ergot. 

2.  Early  artificial  removal  of  the  decidua  or  placenta— active  treatment, 
so  called — in  which  curettage  is  the  routine  plan. 

3.  An  intermediate  or  eclectic  method,  in  which  intervention  is  resorted 
to  only  in  order  to  control  hemorrhage  or  sepsis. 

Each  of  these  methods,  as  remarked,  finds  its  able  advocates.  Winckel,^^' 
Stumpf,^^"  and  Zweifel  "^  are  notably  among  the  endorsers  of  the  first  plan. 
Among  those  who  favor  an  active  intervention  in  all  cases  of  abortion,  at 
least  those  falling  within  the  first  four  months  of  gestation,  are  Diihrs- 
sen,^°®  Auvard,"^  Borel,^"^  von  Brehm,^^^  A.  Martin,  Prochownik,^^*  Week- 
becker-Sternfeld,^*^'  Spondly,^'*^  and  Voltz."^  In  the  last  group,  among 
those  who  take  an  intermediate  stand,  we  find  Charles,"^  Porak,"^  and 
Audebert."^  The  work  will  be  reviewed  in  accordance  with  this  classifica- 
tion and  in  chronological  order,  selection  being  made  from  the  enormous 
mass  of  literature  bearing  on  the  subject. 

Czobos  (1884)  has  already  been  referred  to  as  an  advocate  of  expectant 
treatment.  Winckel,^^''  at  the  first  meeting  of  the  Association  of  Upper 
Bavarian  Physicians,  ])ronounced  himself  in  favor  of  the  most  conservative 
treatment  of  abortion  and  immature  labor,  as  opposed  to  the  spreading 
tendency  in  favor  of  active  interference.  Stumpf  supported  Winckel  at 
this  time,  and  later  published  an  elaborate  tabulated  statement  of  446  cases 
from  the  obstetrical  polyclinic  at  Munich.  ^^^  One  hundred  and  sixt3^-nine 
cases  of  abortion  were  treated  on  the  purely  expectant  plan,  by  tampon 
and  ergot,  and  84  per  cent,  ran  a  favorable  course.  The  number  of  cases 
without  complication  in  w^hich  retention  of  membranes  was  noted,  w^as 
slightly  less  than  of  those  in  which  the  ovum  was  described  as  having  been 


184  REPORT   OP^  THE   SOCIETY    OF   THE    l.VlXli-TX    HOSFITAL. 

expelled  intact.  The  percentage  of  hteiiiorvhage  was  three  times  greater 
in  the  former  than  in  the  latter.  One  hundred  and  lifteen  cases  of  imma- 
ture lal)or  (late  abortions)  showed  worse  results,  91  pursuing  a  favorable 
course,  24  developing  sepsis.  Four  cases  of  sepsis  were  fatal.  Three  of 
them  were  treated  by  manual  removal,  and  death  was  laid  directly  to  this, 
the  author  apparently  forgetting  his  own  statement,  that  interference  was 
not  resorted  to  "  unless  it  was  absolutely  necessary;  "  in  other  words,  unless 
the  ])atient  was  in  extremis  from  lurmorrhage  or  sepsis.  ITis  argument, 
based  on  a  2o  per  cent,  mortality  for  operative  cases  against  2  per  cent. 
for  expectiint,  fails  for  the  same  reason.  Fifteen  cases  are,  moreover,  too 
small  a  number  to  base  sweeping  deductions  upon. 

"Winter '-  claims  that  the  puerperium  is  not  disturbed  b}^  retention  of 
decidua,  38  per  cent,  of  his  cases  becoming  pregnant  early,  while  after 
complete  removal,  conception  was  seen  in  only  0.20  per  cent.  Puppe^*^  has 
])ublished  the  results  in  Winter's  clinic.  Winter  makes  this  concession  to 
the  advocates  of  active  treatment,  that  partly  detached  and  floating  rem- 
nants of  retained  decidua  might  become  dangerous,  and  hence  should  be 
removed.  Olshausen,  Schrtt^der,  and  Kiistner^^'  advocate  the  expectant 
])lan  also. 

Varnier's  '^  conclusions  from  a  series  of  501  cases  are  that  retention  of 
the  ])lacenta  is  exceptional,  and  retention  prolonged  for  more  than  twenty- 
foui-  houi's  is  very  unusual.  lie  allows  nature  to  act  until  the  ])lacenta  is 
in  the  vagina,  and  then  removes  it  manually.  Immediate  delivery  is  indi- 
cated in  hiemorrhage,  Init  he  does  not  clear  away  the  dehris.  He  found 
"  complete  "  expulsion  to  occur  onl}^  48  times  in  liis  series. 

Boetus,'^  who  iirst  published  satisfactory  results  in  ten  curettage  cases, 
advises  against  a  ])i'e]iminary  dilatation  of  the  cervix,  es])ecially  in  ])res- 
ence  of  sejjsis  and  inflammation  of  the  adnexa,  but  uses  tlio  curette  freely 
in  all  cases  with  good  results.  lie  found  complicating  pelvic  disease 
improved  after  curetting,  made  worse  by  dilatation.  Great  care  must  be 
used  to  remove  every  part  of  the  retained  placenta  (1877). 

After  an  experience  Avith  90  cases,  Fehling^^s  (i878)  believes  insti'u- 
mental  removal  of  ovum  or  secundines  is  absolutely  without  djinger  under 
antise])tic  precautions,  and  favors  active  pro]>]iylactic  interference,  since  it 
cau.ses  ra[)id  involution  and  saves  the  woman  subsequent  suffering  from 
j)elvic  disease.  He  was  able  to  demonstrate  the  retention  of  decidua  in  all 
cases  which  he  subjected  to  curettage.  Eleven  of  his  cases  Avere  septic  when 
first  seen,  antl  two  were  fatah  but  in  these  the  source  of  infection  was 
clearly  trac<!d. 

Jirion*'  reports  24  (rases  of  retained  ])la('enta  after  abortion,  with  11 
deaths;  he  divid(!S  tliein  into  two  cln-oiiological  pei-iods,  lss;',-lS8S,  1888- 
1802.  During  the  Iirst.  irrigalioii  only  \v;is  cniplcy*'*! :  (hiring  the  second, 
manual  cun-lting  was  added.  Four  of  (Ught  casi^s  (50  per  cent.)  died  in 
the  first  jKM-iod;  five  of  twenty  ('2;")  ])er  cent. )  in  tlu^  second.  Tliice  and 
four  respectively  were  fa  1' ;id\'a need  in  sepsis  wlieii  admitted  to  the  Hospital. 
r)initting  tliesr*,  the  ))ei'e(;ntages  are  20  and  O.r.,  difleniuce  enough  to 
inaki-  tlie  autlioi-  pronounee  in  favor  of  active  trealni(;nt  and  most  careful 


THE    PREMATniE    INTERRUPTION    OF    PREGNANCY.  185 

antisepsis.      His  preference  for  the  finger  is  founded  on  its  sensitiveness. 
He  gives  these  indications  for  interference : 

1.  In  case  of  death  and  maceration  of  the  foetus. 

2.  In  every  case  after  incom])lete  abortion  in  which  the  temperature 
rises  to  38  degrees  Centigrade.  The  patient  must  be  at  once  isolated  and 
cleUvered.  The  accidents  in  abortion  are  sepsis  and  hgeraorrhage,  but  as  to 
their  rehitive  frequency  it  is  difficult  to  say.  Sepsis,  however,  occurred  24 
times  to  -I  of  haemorrhage  in  the  author's  28  cases  of  placental  retention. 

In  his  paper  read  before  the  Buffalo  Obstetrical  Societ}^,  M.  Ilartwig  ^'^^ 
lays  down  the  rule  that  it  is  best  to  remove  what  may  become  septic  if  not 
already  so.  He  finds  dilatation  seldom  necessary,  scraping  the  mucous 
membrane  with  a  dull  curette  until  nothing  but  blood  comes  away.  Ergot, 
he  finds,  will  not  stimulate  abortion,  but  will  often  prevent  it. 

Felsenreich  ^^^  reports  20  cases  of  puerperal  curetting,  and  finds  it  well 
borne  in  presence  of  parametritis  and  perimetritis,  even  of  inflammation 
of  the  adnexa.  He  has  seen  women  who  aborted  habitually,  go  to  term 
after  curetting. 

Weekbecker-Sternfeld  ^'''  prefer  instrumental  to  digital  curettage  because 
(1)  the  danger  of  infection  is  less,  (2)  less  room  is  required,  (3)  removal  of 
decidual  remnants  is  more  positive,  and  (4)  there  is  less  disturbance  and 
injury  to  the  patient.  They  give  as  indications  for  the  use  of  the  instru- 
ment: («)  in  the  first  three  months  (1)  retention  of  ovum  intact,  adherent 
or  (2)  free ;  (3)  retention  of  secundines ;  (h)  in  later  months,  for  removal  of 
placental  cotyledons,  (c)  as  an  irritant  in  an  atonic  uterus,  {d)  for  removal 
of  placental  polypoid  growths. 

Moses  ^^  has  reported  61  cases  of  threatened  and  incomplete  premature 
deliver}^  Ten  were  frankly  septic,  51  non-septic.  Expectant  treatment 
was  pursued  in  19  cases,  while  42  were  curetted — 7  for  se|)sis,  9  for  haemor- 
rhage, 26  as  a  prophylactic  measure.  The  result  was  apparently  good  in 
all  cases,  with  a  single  exception,  a  septic  patient  i7i  artimdo  mortis  when 
brought  in. 

Braun  ^^^  says  every  j^hysician  should  know  how  to  use  a  curette  and 
use  it ;  Pick  ^°^  has  employed  it  as  a  prophylactic  procedure ;  Schwarz  ^^^ 
recommends  it  whenever  the  ovum  is  not  intact,  and  always  in  sepsis,  even 
when  the  patient  is  in  collapse. 

Dahlmann  ^^^  states  that  in  130  cases  the  tampon  was  indicated  only  four 
times,  for  the  reason  that,  although  it  is  the  ideal  method  when  practical, 
the  physician  is  usually  called  too  late  to  apply  it.  His  method  is  digital 
curetting,  followed  by  instrumental.  The  finger  cannot  remove  the  bits  of 
tissue  which,  left  behind,  are  fruitful  sources  of  trouble.  One  hundred 
cases  treated  in  this  manner  recovered  without  complication.  Dahlmann 
has  observed  the  usual  chill  and  temperature  rise  in  curetted  septic  cases, 
and  though  he  believes  in  thoroughly  cleansing  the  uterus,  there  was  no 
decomposition  seen  in  three  of  his  incomplete  cases  of  several  months' 
duration. 

Diihrssen,^^^  perhaps  more  than  any  other  man,  has  brought  the  advan- 
tages of  curettage  home  to  every  obstetrician.      He  empties  the  uterus  as 


186  REPORT   OF   THE   SOCfETV    OF   THE    LYTX(i-lX   HOSPITAL. 

soon  as  the  abortion  bei-onios  inevitaMc.  Two  only  of  l^>-2  cases  treated 
by  him  died,  in  s))ite  of  the  fact  that  many  were  advanced  in  sepsis  wlien 
first  seen,  or  had  sutfered  from  severe  luemori'hages.  Contrasting-  the 
expectant  and  active  phins  of  treatment,  he  asks,  *'  Why,  if  interference  is 
tt>-day  considered  less  (hmgerons  than  abortion,  not  make  sure  that  every- 
thing  has  been  removed,  when  it  can  be  so  readily  done  ?  "  Involution 
and  time  are  necessary  for  convalescence  after  abortion ;  the  one  is  hastened 
tiie  other  cut  short  after  curetting.  This  is,  of  course,  a  boon  to  the  work- 
ing classes.  The  expectant  plan  requires  two  weeks  for  itself  alone;  after 
instrumentation  the  j)atient  leaves  her  bed  on  the  fifth  day.  Pain  and 
physical  discomfort,  as  well  as  mental  perturbation,  are  greater  than  in  the 
exi)ectant  methotl.  Moreover,  a  large  ])ro]K)rtion  of  so-called  complete 
abortion  cases  are  followed  by  luemoi-riiages,  subinvolution,  acute  and 
chronic  sepsis.  Haemorrhage  is  always  greater  with  expectant  treatment. 
Not  more  than  half  an  ounce  is  lost  by  instrumentation  before  the  fourth 
month. 

Diihrssen,  unlike  Munde,  Boetus,  and  Ihiclmor,  does  not  use  the  curette 
to  remove  placenta  after  the  twelfth  ^veek.  It  is  not  ])ossil)le  or  safe  to  do 
so,  and  as  a  greater  number  of  abortions  occur  at  the  third  month,  the 
method  must  be  a  combined  one.  The  separation  of  the  placenta  is  readily 
accomjilished  by  the  finger;  the  curette  removes  the  decidua  vera.  In  the 
first  two  months,  clearage  can  be  accomplished  with  curettage  alone,  the 
canal  admitting  the  linger  with  difficulty  and  pain  if  anaesthesia  is  not  used. 
Uterine  atony,  as  in  our  cases,  is  controlled  l)y  irrigation,  and  tamjwnade 
with  iodoform  gauze.  Ergot  is  rarely  called  for;  the  placental  forceps 
occasionally. 

Doderlein,'-'^  also  an  advocate  of  active  treatment,  uses  only  digital 
curetting  for  recent  cases,  reserving  the  instrument  for  instances  of  acute 
and  chronic  endometritis.  He  emplo^^s  anassthesia  always.  If  the  os  will 
not  admit  a  finger,  he  uses  a  laminaria  tent,  and  evacuates  the  next  day. 
lie  reports  500  cases  so  managed  in  ZweifePs  clinic,  and  has  operated,  as 
Avell,  in  loo  cases  of  profuse  ha?morrhage  following  aboi-tion.  Of  the  500 
cases,  three,  septic  when  admitted,  died  under  expectant  treatment.  The 
100  cases  showed  ]iolypi  and  endometritis,  and  took  weeks  to  cure. 

Iloc-het**^  pui-sues  much  the  same  plan,  dilating  with  tents,  and  scraping 
first  with  a  blunt,  tlien  with  a  sharp,  curette  without  anaesthesia.  AVitli  a 
large  curette,  he  claims,  there  is  little  danger  of  ])erfora,ting  the  uterus. 

Eckstein  '•''■  has  rej)orte(l  (!<»  cases  whicli  wei-e  curetted,  and,  in  sj)it(^  of 
complications,  all  made  good  recoveries,  in  s('])tic  cases,  Ik;  pai'ticuhirly 
declar(?s  no  time  should  b(^  lost  in  ch'ui'ingand  disinfecting  the  utciMUt!  cavity. 

Authors  might  be  (juot(*d  in  this  connection  in  practically  endless  ai-ray, 
for  new  ones  are  constantly  being  achhul  to  thi-  ;iliv;i(ly  long  list.  AVe  may 
be  excused  for  naming  in  addition,  as  increasing  the  weight  of  ex])e)'i- 
encc  on  the  side  of  interference;,  Palmer,  nonifield.''"'  Locke,''''  (irigoriawitz 
(00  cases  with  one  death),  Ku])penheim  '*  of  Ilciilclberg  (100  cases,  treated 
by  manual  and  instrumental  removal  in  llir-  lirsl  three  months,  latei-  by 
han«l  only;,  Chaliex.'*  liibot,""  von  dcr  (ioll/..'" 


TPIE   PREMATURE    INTERRUPTION    OF   PREGNANCY.  187 

Between  these  two  extremes  of  treatment  stands  the  third  class,  com- 
posed of  men  who,  not  caring  tcj  interfere  in  every  case,  or  even  in  a 
majority  of  cases,  are  still  unwilling  to  allow  nature  to  take  its  course  Avhen 
the  uterus  is  a  focus  of  septic  infection.  They  claim  that  curettage  does 
not  always  give  good  results  even  when  done  by  skilled  operators. 
Another  objection  offered  is  the  elaborate  preparation  for  operation. 
Charles  ^"  cites  cases  to  prove  the  former  objection,  and  considers  curettage 
after  abortion  necessary  only  when  there  is  an  old  endometritis,  or  when 
the  finger  fails  to  remove  the  placenta.  Yon  JBraun-Fernwald  ^""^  holds 
that  the  passive  attitude  is  best.  Lauros  ^^®  waits  until  urgent  symptoms 
demand  interference.  Stratz  ^''  believes  that  active  treatment  is  only 
required  for  haemorrhage  and  fever,  and,  even  Avhen  driven  to  it,  prefers  the 
finger  to  an  instrument.  In  five  only  of  486  cases  did  he  deem  it  necessary 
to  use  the  curette.  All  of  these  were  septic,  and  in  all  there  was  a  tetanic 
condition  of  the  uterus,  due  to  previous  administration  of  ergot.  Deme- 
lin  "^  advises  removal  of  the  placenta  with  two  fingers  at  three  months;  at 
four  months  it  can  be  left  to  nature.  Yelitz  "^  concludes  from  a  study  of 
4,333  cases  in  Tauffer's  clinic  that  only  when  there  are  decided  indications 
need  one  resort  to  interference.  Doleris^^'^  is  especially  identified  with 
ecouvillonage  of  the  uterus,  a  procedure  similar  to  the  cleaning  of  lamp 
chimneys,  the  organ  being  swept  out.  Misrachi^^^  advocates  it  also. 
Porak  ^^^  judged  intervention  necessary  in  only  25  cases  out  of  326,  and  in 
these  the  operation  was  extremely  simple.  His  percentage  of  fever  in  cases 
of  intervention  was  36,  and  his  mortalit}^  4  per  cent. ;  in  spontaneous 
delivery,  10  per  cent,  and  0.3  per  cent,  respectively.  He  omits,  however, 
all  mention  of  details  regarding  sepsis,  its  appearance  in  expectant  cases, 
etc.,  and  the  late  results  of  his  treatment.  Misrachi^^^  undertook  to 
answer  Dr.  Porak,  and  stated  that  since  he  began  interference  in  cases 
of  retention,  he  had  had  92  cases  of  abortion.  In  60,  or  65.2  per  cent., 
intervention  was  necessary,  the  large  proportion  being  caused  by  the  char- 
acter of  his  clientele.  In  47  cases  he  was  called  at  the  first  symptom,  and 
of  these,  32  terminated  spontaneously,  in  15  he  intervened  (13  of  haemor- 
rhage, 2  of  sepsis).  The  proportion  of  bleeding  controverts  Porak' s  state- 
ment as  to  the  negligibility  of  this  as  an  indication  for  interference. 

Treatment  of  the  Peematube  Inteeeuption  of  Peegnanct   as  Caeeied 

Out  by  This  Hospital. 

Treatment  of  Abortion. 

By  reference  to  the  tables  it  will  be  seen  that  of  the  total  417  cases  of 
abortion,  324  were  subjected  to  some  form  of  curettage;  the  average  period 
between  the  time  the  cases  first  came  under  the  observation  of  the  Hospital 
official  and  the  curettage  being  8  hours  45  minutes  in  early  abortions,  10 
hours  48  minutes  in  late  abortions.  The  diagnosis  of  inevitable  abortion 
or  of  the  fact  that  the  accident  had  already  occurred  (incomplete  ?)  being 
made,  and  leaving  out  of  consideration  the  amount  of  hgemorrhage  as  an 
indication  for  interference,  the  patient  is  plainly  told  that  an  operation  is 
necessary ;   and  if,  upon  explaining  the  danger  of  the  situation  to  her,  con- 


188 


REPORT   OF   THE    fiOCTETY    OV   THE    LYIN(MX    HOSPITAL. 


sent  for  curettjige  cannot  be  secured,  she  is  treated  according  to  Procedure 
I.  or  II.  (see  infra)  or  referred  to  another  institution  or  her  private  ph3^si- 
cian.  The  patient's  consent  having  been  obtained,  curettage  is  performed 
within  as  short  a  time  as  possible. 

Pr(>C('(I>(/Y  I. — As  a  rule,  during  the  ]ieriod  covered  bv  this  article,  the 
treatment  of  interru])ted  })regnancy  in  the  tirst  three  months  of  gestation 
has  been  an  active  one,  as  the  following  table  indicates : 

Treatment  in  417  Cases  of  Abortion. 


Late 
Abortions. 


Instrumental  curettage  only 

Combined  instrumental  and  digital  curettage 

Digital  curettage  only 

Intrauterine  douche  only 

Expectant  treatment 


79 

27 
5 

7 


175 


Time  tuat  Elapsed  Between  First  Visit  by  the  Hospital  Official  and 

Operation. 


Average  |)eriod  . . 
Longest  period  , . . 
Shortest  period  .  . 
Op(3ration  at  once 


early  abortions. 
160  Observations. 


8  hours  45  minutes. 
3  weeks. 
Few  minutes. 
In  129  cases. 


LATE    ABORTIONS. 

96  Observations. 


10  hours  48  minutes. 
2  weeks. 
Few  minutes. 
In  55  cases. 


In  addition  to  the  labor  bag  (see  Ite])ort)  which  has  already  been  sent 
to  tlie  ]);itient's  liome,  another  one,  known  as  the  ''  curettage  bag,"  is  sent, 
which  coMtains  the  followin";  articles: 


Chloroform. 

Mask  ami  tbopijcr. 

Ether  and  cone. 

N'aginal  brush. 

Kelly  pad. 

Douche  bag. 

Kubljer  instruiMcnt  trays,  8. 

Crutch. 

Xail  l)ruslies,  '•>. 

Solution  pans,  2. 


Contents  of  Clrettage  Bag. 

Gauze — one  tube  iodoform,  one  tube 

])lain  sterilized. 
Sterilized  towels,  4. 
Bichloiide  tablets. 
Ccii'l)olic  acid. 
Ergot. 
Whiskey 

Agar-agar  tubes  and  culture  swabs,  4. 
Catheter,  glass. 
Sims's  speculum. 


Fig  1. — Curettage  Bag, 


THE   PREMATURE    INTERRUPTION    OF    PREGNANCY. 


189 


Edebobls's  speculum. 
Yolsella,  2. 
Dressing  forceps,  2. 
Curettes,  3  sharp  and  3  blunt. 
Uterine  sound. 
Cervical  dilator. 
Bandage  scissors. 
Fritscb  return  catheter. 


Douche  tube,  glass. 

Sterilized  cotton,  two  tins. 

Soap. 

Lysol. 

Alcohol. 

Digitalis. 

Strychnine. 

Agar-agar  exposure-plate,  1. 


Two  of  the  resident  staff  of  the  Hospital,  accompanied  by  one  or  more 
students,  the  latter  for  the  purpose  of  instruction,  then  proceed  to  the  case ; 
all  preparations  are  made,  the  patient  is  anaesthetized  (with  ether  in  most 
cases),  placed  upon  the  kitchen  table  so  as  to  secure  light  from  window  or 
lamp,  the  Kelly  pad  adjusted,  and  the  legs  are  secured  in  the  lithotomy 
position  by  canvas  crutch.     (See  Fig.  1.) 

The  vulva  now  is  usually  shaved,  and  always  scrubbed  with  lysol  solu- 
tion, five  per  cent. ,  or  with  green  soap,  using  a  stiff  brush.  The  vagina  is 
then  cleansed  with  the  same  solutions,  and  at  different  periods  in  the  ser- 
vice of  the  Hospital  a  stiff  brush,  a  soft  five-inch  jeweler's  brush,  and 
swabs  of  sterilized  absorbent  cotton  or  gauze  upon  long  dressing  forceps 
have  been  used  for  this  purpose. 

The  field  of  operation,  including  the  vagina,  is  now  cleared  of  soap 
with  boiled  water,  and  a  final  thorough  irrigation  with  sublimate  solution 
isooo)  follows. 

By  means  of  towels,  sterilized  and  brought  from  the  Hospital,  the  imme- 
diate septic  surroundings  are  covered  so  as  to  exclude  contact  infection. 

The  perineum  is  now  depressed  with  a  speculum,  the  cervix  grasped 
and  brought  down  with  a  volsella  forceps,  and,  if  required,  the  os  is  freely 
and  rapidly  dilated  with  a  steel  dilator  of  the  Goodell  type. 

The  uterine  cavity  is  now  freely  irrigated  w4th  a  sublimate  solution 
(¥oVo)?  ^  digital  examination  is  made,  followed  by  another  irrigation,  and 
the  uterus  is  thoroughly  curetted,  usually  both  sharp  and  dull  instruments 
being  used,  and  during  the  operation  the  cavity  is  repeatedly  washed  out. 

At  certain  periods  in  the  history  of  the  Hospital,  the  use  of  the  sharp 
curette  has  been  confined  to  cases  in  which  evidences  of  chronic  inflamma- 
tion of  the  uterus  were  present. 

Iodoform  gauze  was  not  made  use  of  for  drainage  among  the  earlier 
cases ;  later  the  uterus  and  vagina  were  rather  tightly  packed ;  and  in  the 
more  recent  cases  a  single  strip  only  of  gauze  was  introduced  to  the  fundus, 
and  the  vagina  rather  tightly  packed  with  the  same  material. 

Bacteriology. — For  purposes  of  bacteriological  study,  four  cultures  are 
taken  at  the  time  of  the  operation,  the  first  and  second  from  the  vagina 
and  uterus  before  cleansing  these  parts,  and  the  third  and  fourth  from  the 
same  points  after  cleansing  and  curetting.     (See  Bacteriology.) 

In  instances  in  which  the  diagnosis  of  abortion  is  questionable,  no 
embryo,  foetus,  or  placenta  having  been  found,  but  the  symptoms  point  to 
an  incomplete  abortion,  scrapings  obtained  with  the  curette  are  placed  in 


190  REPORT  OF  thp:  society  of  the  lvincmn  hospital. 

alcohol,  marked  with  the  Hospital  luimlier  o\:  the  case,  and  sent  to  the 
]iathologist  for  microsco])ical  examination.     i^lSee  Tathology.) 

]*i'oce(1ure  J  I.  —  Dui'ilii:'  certain  periods  a  few  cases  of  inevitable  or 
incomplete  abortion,  in  w  hicli  the  patient  refuses  to  take  an  anaesthetic,  and 
in  which  all  s\ini)tonis  of  se])sis  are  absent,  have  been  accepted  by  the 
llos|)ital  and  treated  on  a  partially  expectant  plan. 

The  j)atient  is  placed  in  the  lithotomy  position  and  tlic  vulva  and  vagina 
are  cleansed  as  in  I'rocedure  I.  Then,  if  the  dilatation  of  the  os  permits 
it,  curettage  is  performed  as  above,  otherwise  nothing  further  is  done.  In 
a  few  of  these  cases  of  the  incomplete  variety,  the  uterus  was  irrigated  Avitli 
a  sul>limate  solution,  and,  if  possible,  a  strip  of  gauze  introduced  for  a  drain, 

I'roct'dnre  III. — A  few  nou-septic  cases  have  been  accepted  in  which  all 
interference  other  than  a  digital  examination  has  been  refused  by  the  patient. 

Here  a  ])urely  expectant  treatment  was  followed,  the  external  genitals 
only  being  waslied  with  a  sublimate  solution  {-^-^^  before  and  after  the  dig- 
ital examination.  These  cases  could  not  be  kept  under  observation  very 
long,  as  the  patients  usually  left  their  beds  on  the  third  or  fourtli  day  to 
attend  to  their  housework. 

Aftt'i'-Treatment. — Patients  are  kept  upon  fluid  diet  for  two  days  after 
curettage,  and  the  vulva  is  washed  once  or  twice  daily  during  the  puer])e- 
rium  with  a  sublimate  solution  (^o-y).  If  the  tenijierature  and  ]Hilse  remain 
normal  the  vaginal  and  uterine  gauze  is  left  in  sliu,  until  the  fourth  or  fifth 
day,  then  removed,  and  a  vaginal  sublimate  douche  (-joinr)  given.  Should 
evidences  of  se])sis  show  themselves,  the  vaginal  gauze  is  first  removed  and 
the  vagina  irrigated;  should  they  then  persist,  the  uterus  is  em])tied  of 
gauze  and  iri'igated,  and  the  washing  is  repeated  if  necessary. 

Treatment  and  Results  in  Our  2-1:2  Cases  or  Early  Abortion. 

Treatment  of  Early  Abortions. 

In  the  study  of  any  particular  line  of  treatment  for  abortion  and  the 
results  obtained  therefrom,  the  importance  of  making  a  distinction  between 
cases  of  septic  and  non-septic  when  first  seen  cannot  be  too  strongly  em- 
])hasiz('d. 

The  following  tallies  will  show  at  a  glance  the  treatment  and  results  in 
the  several  classes  of  cases: 

Treatment  in  Early  Abortions.  r^ 

(;ases. 

Instrumental  curettage 1C6 

('oMd)ined  instrumental  and  digital  curettage 45 

I )igital  cur(;ttage 3 

Intrauterine  douche  only 6 

P^xpectant  treatment 22 

Total 242 

Cases. 
No.  of  cases  of  early  abortion  with  fever  wlicii  lirst  seen    ...        9 

"             "                 without  fever  when  lirst  seen.    283 
Total 242 


THE  PREMATURE  INTERRUPTION  OF  PREGNANCY. 


191 


Treatment  of  9  Cases  of  Eakly  Abortion  with  Fever  when  First  Seen. 

Cases. 

Curettage  (1  digital,  6  instrumental) 7 

Expectant  treatment 2 

Total 9 

Treatment  of  233  Cases  of  Early  Abortion  without  Fever  when 

First  Seen. 

Cases. 

Instrumental  curettage  only 160 

Combined  instrumental  and  digital  curettage tto 

Digital  curettage 2 

Intrauterine  douche 6 

Symptomatic  or  expectant 20 

Total 233 

Cause  of  the  Fever,   Treatment,  and   Termination  of   the  9  Cases  of 
Early  Abortion  with  Febrile  Symptoms  when  First  Seen. 


C.  X, 


213 

727 

781 

l,01i 

1,153 

2,270 

5,4:61 

5,781 
7,521 


Cause  of  Fever. 


Sepsis 


Tuberculosis  and  sepsis  (?) , 


Treatment. 


Digital  curettage 


Expectant 

Instrumental  curettage 

Expectant 

Instrumental  curettag-e 


Duration  of 
Symptoms. 


1  da}^. 

3  days. 
1  day. 
3  days. 
Few  hours. 
I*^o  record. 
5  days. 
3  days. 


Eesults   of   the    233    Cases    of    Early   Abortion    that   were   without 
Febrile    Symptoms  when  First  Seen. 

Cases. 

Undisturbed  puerperium 214 

Developed  fever 19 


Of  the  214  cases  that  resulted  in  an  undisturbed  puerperium,  the  treat- 
ment was  as  foUows: 

Cases. 

Curettage 188 

Expectant 26 


192 


REPORT   OF   THE   SOCIETY    OF   THE    LYING-IN    HOSPITAL. 


Cause  of  thk  Fkvkr,  Treatment,  and  Termination  in  the  19  Cases  of 
Early  Abortion  that  Developed  Febrile  Symptoms  in  the  Service 
OF  THE  Hospital. 


C.  N. 


Cause  of  Fever. 


117 
1,013 
1,243 
1,612 
2,275 
2,327 
2,8<M 
3,  SO") 
3,703 
4,101 
4,252 
4,909 
5,017 
5,732 
0,223 
6,719 
7,022 
T,738 


Sepsis 

'Bronchitis  (?) 

Se]>sis 

lUnknown 

Pleiiris>'  and  sepsis 

Sepsis 

Unknown 

Sei)sis 

Tuberculosis 

:  Unknown 

Sepsis 

;Consti])ation 

Sepsis 

lUnknown 

j  Pneumonia 

jConstipation 


Treatment. 


Instrumental  curetta«re 


Duration  of 
Symptoms. 


1  day. 
3  days. 

2  days. 

3  days. 
5  days. 

1  daj^. 
Few  hours. 

4  days. 
No  record. 
Few  hours. 
0  days. 
Few  hours. 

Li  a 

2  days. 
Few  hours. 

2  days. 
Few  hours. 
No  record. 

3  days. 


Treatment  and  Eesults  in  Our  175  Cases  of  Late  Abortion. 

Tredtment  of  Ldie  Ahortions. 

As  will  be  seen  by  reference  to  our  table  of  the  premature  interruption 
of  ])regnancy,  from  the  beginning  of  the  fourth  until  the  completion  of  the 
sixth  and  three-fourths  month  of  gestation,  the  treatment  is  usually  of 
the  active  variety  in  the  early  portion  of  this  period,  because  clinically 
we  are  unable  to  draw  the  line  so  sharply  between  early  and  late  abortions 
as  some  authorities  would  have  us  do,  and  in  the  fourth,  fifth,  and  sixth 
months  the  treatment  becomes  less  and  less  aggressive,  until  it  gradually 
merges  into  that  of  premature  labor  and  labor  at  term. 


Tkkatmknt  in  Late  Abortions. 

Cases. 

Instrumental  curettage 79 

(Joml)ined  instrumental  and  digital  curc;ttag(j   27 

Digital  curettage 5 

Intrautc^rine  douche  only 7 

Expectant  treatment 57 

Total 175 


THE  PREMATURE  INTERRUPTION  OF  PREGNANCY. 


193 


The  following  table  shows  at  a  glance  the  ratio  of  actual  interference 
progressively  diminishing  in  the  successive  months : 

Delivery    of    the    Placenta   in    Late    Abortions,    Showing    Ratio    of 
Intrauterine  Interference  Diminishing  in  the  Successive  Months. 


Month  of  Gestation. 


At  4th  month,  including  3|- 
months 

At  5th  month 

At  6th  month,  including  6|- 
months 


66 
15 


an 

C/2 


7 
12 

18 


7 
3 

10 


XI 


1 

2 

15 


o 
o 


Ratio  of 
Intrauterine 
Interference. 


73-88  =  1  in  1 
18-37  =  1  in  2 

13-50  =  1  in  4 


Recognizing  as  we  do  the  fact  that  the  real  criterion  of  late  abortions 
is  the  marked  prolongation  of  the  third  stage  of  labor,  naturally  the  inter- 
est centres  at  this  point. 

It  is  obvious  that  the  tendency  in  our  treatment  has  not  been  to  await 
the  natural  course,  the  spontaneous  detachment  and  expulsion  of  the  pla- 
centa, even  in  cases  not  complicated  by  dangerous  haemorrhage  or  sepsis  of 
the  secundines,  but  to  clear  tlie  uterus  as  quickly  as  possible  after  the 
diagnosis  of  an  inevitable  or  incomplete  abortion  is  made. 

Cases  falling  in  the  first  portion  of  this  period  are  subjected  to  the 
same  active  treatment,  already  described,  as  is  applied  to  instances  of 
inevitable  or  incomplete  abortion.  Not  only  do  w^e  believe  that  the  char- 
acter of  the  outdoor  service  and  environment  of  the  patients  demand  and 
justify  this  course,  but  the  results  obtained  strengthen  our  ])osition. 

Here  again  we  cannot  too  strongly  emphasize  the  importance  of  mak- 
ing a  distinction,  when  giving  the  results  of  any  particular  line  of  treat- 
ment for  the  premature  interruption  of  pregnancy,  between  cases  non- 
septic  when  first  seen  or  operated  upon  and  those  that  are  septic. 

The  following  tables  indicate  the  line  of  treatment  in  175  cases  of  late 
abortion,  of  which  20  were  febrile  when  first  seen,  and  155  were  non- 
febrile. 

Treatment  in  Late  Abortions. 

Cases. 

Instrumental  curettage 79 

Combined  instrumental  and  digital  curettage 27 

Digital  curettage 5 

Intrauterine  doucl^  only ^ 

Expectant  treatment 57 

Total 175 

13 


194 


REPORT   OF  THE  SOCIETY   OF  THE   LYING-IN   HOSPITAL. 


Dklivekv  of  the  Placenta  in  Late  Aboktions.    Q^^g^g 

Spontaneously  delivered 35 

Placenta  ex]iressed 19 

Placenta  removed  manually  l)y  Hospital  official 20 

Curettage  after  manual  removal 87 

Kot  noted  on  liistury 8 

Total 175 

No.  cases  of  late  abortion  with  fever  when  first  seen.  .  . .     2(> 
»'       »'        "  ''        without  fever  when  first  seen .   155 

Total 175 

Treatment  of  the  2o  Cases  of  Late  Abortion  that   had   Fever   when 

First  Seen.  ^^^^^^ 

Placenta  delivered  spontaneously 2 

Placenta  expressed 2 

Placenta  manually  removed  by  Hospital  official 4 

Curettage  after  manual  removal 4 

Instrumental  curettage 12 

Results  of  the  Treatment  of  the  20  Cases  of  Late  Abortion  that 
WERE  Febrile  when  First  Seen. 
The  following  table  gives  the  cause  of  the  fever,  the  treatment,  and  the 
duration  of  the  sym]^toms  in  the  20  cases  of  late  abortion  with  fever  when 
fii"st  seen  by  the  Hos})ital  official. 


C.  X. 

Cause  of 
Fever. 

Placenta. 

Curettage. 

Duration  of 
Symptoms. 

215 

283 

Sepsis 

Manual  extraction . . 

Instrumental  .... 

a 
a 
a 
i( 
u 

Dio'ital 

Few  hours. 
1  day. 

871 

Unknown. 

1,177 
1  002 

3  (lavs. 

Few  hours. 

1,785 
2,11>2 
2,755 
3,808 

2  days. 

Spontaneous 

^lanual  extraction .  . 

Instrumental  .... 

i( 

a 
u 
u 
u 

4  davs. 
1  day. 

4,774 
5,044 



Spontaneous 

2  days. 
Few  hours. 

5  219 

(I             a 

5,<;47 

a             a 

5,702 

1  d:iv. 

0,885 

.. 

^[anual  extraction .  . 

" 

0,5«;2 

Unknown  

Sej)sis 

Expressed 

>' 

0,015 

Instrumental  .... 

9  ii 
Expectant 

VvAV  hours. 

7,070 

14  days. 

8,087 
9,643 

Consti|)ati<;n. .  . 

i 
1 

Manual  exti'actioii .  . 
Expressed 

Few  hours. 

THE    PEEMATURE   INTERRUPTION   OF   PREGNANCY. 


195 


Treatment  of  the  155  Cases  of  Late  Abortion  that  were  Non-Febrile 

WHEN  First  Seen. 

Cases. 

Placenta  spontaneously  delivered 33 

Placenta  expressed 17 

Placenta  removed  manually  by  Hospital  official 25 

Curettage  after  manual  removal Y2 

JN'ot  noted 8 

Total 155 

Results  of  the  Treatment  of  the  155  Cases  of  Late  Abortion  that 
were  Kon-Febrile  when  First  Seen. 

Cases. 

Undisturbed  puerperium 137 

Developed  febrile  symptoms 18 

Cause  of  the  Fever,  Treatment,  and  Duration  of  the  Symptoms  in 
THE  18  Cases  of  Late  Abortion  that  Developed  Febrile  Symptoms 
IN  THE  Service  of  the  Hospital. 


C.  K 


64 

407 

567 

580 

911 

939 

1,055 

1,267 

1,326 

1,922 

4,198 

4,242 

4,309 

5,051 

5,635 

5,656 

7,260 

8,872 


Cause  of 
Fever. 


Sepsis 

Bronchitis  . , 

Sepsis 

Unknown  .  . 
Sepsis 

Constipation 

Sepsis 

a 

Constipation 
Unknown .  .  , 

Sepsis  . .    . . . 


Placenta. 


Spontaneous  .... 
Manual  extraction 

Expressed 

Manual  extraction 

Expressed 

Manual  extraction 


Spontaneous 
Broken  up  . . 
Expressed .  . . 
Spontaneous 
Broken  up  . . 


Manual  extraction 

Broken  up 

Expressed 

Spontaneous  .  .  .  . 


Curettage. 


Instrumental 


Instrumental 


Instrument,  and  dig. 


Instrumental 


Instrument,  and  dig- 
Instrumental  


Instrument,  and  dig. 
Instrumental 


Instrumental 


Duration  of 

Symptoms. 


Few  hours. 
2  days. 
Iday. 


3  days. 
2  days. 
Few  hours. 

4  days. 
1  day. 
Few  hours. 


8  days. 
3  days. 


Note. — Winckel  and  Stumpf  in  their  115  cases  of  late  abortion  found 
that  manual  detachment  of  the  placenta  was  strictly  indicated  in  8  cases 
only,  or  6.95  per  cent.;  the  placenta  was  delivered  spontaneously  in  77 
cases,  expressed  in  17,  removed  or  attempt  at  removal  made  by  an  outside 
physician  in  7  cases,  removed  manually  by  their  own  phj^sicians  in  8. 

Of  their  115  cases,  6  w^ere  fatal  in  consequence  of  immature  labor, 


196  REPORT   OF   THE    SOCIETY    OF   THE   LYING-IN   HOSPITAL. 

5  of  sepsis,  1  of  lui?niorrluige.  Three  of  the  four  cases  of  fatal  sepsis  had 
been  subjected  to  manual  removal  of  the  placenta,  giving  a  mortality  for 
manual  interference  of  '20  per  cent.,  and  for  expectant  or  symptomatic 
treatment  of  only  2  per  cent. 

Thev  also  claim  a  morbidity  from  sepsis  under  an  expectant  treatment 
of  l-t.a  }>er  cent.,  and  under  operative  interference  of  -iO  per  cent.;  but 
they  do  not  inform  us  what  proportion  of  their  cases  were  septic  when 
seen,  and  what  pro]wrtion  became  so  under  an  expectant  treatment.  To 
quote  their  own  words,  '*  On  the  strength  of  these  figures  one  might 
well,  and  with  a  clean  conscience,  defend  and  advocate  a  symptomatic 
treatment  as  oj^posed  to  the  operative."  In  35  of  their  cases  the  third 
staire  was  allowetl  to  continue  over  six  hours. 

Treatment  and  Results  in  Early  and  Late  Abortions  in  the  Several 
Months  of  Gestation. 

Eakly  Abortions. 

Cases. 

Second  month G9 

Third  month 165 

Unknown S 

Total "2^2 

Of  the  above  242  cases  belonging  to  the  first  three  months,  233  showed 
no  fel)rile  symptoms  when  first  seen  by  the  Hospital  official,  9  showed 
feljrile  symptoms  when  first  seen. 

Tekmixatiox  of  233  Cases  ]^on-Febkile  when  First  Seen. 

Cases. 

Subjected  to  immediate  curettage 131 

Allowed  to  run  a  spontaneous  course 1()2 

Of  131  subjected  to  immediate  curettage: 

Cases. 

Fever-free  puerperium  resulted 120  or  91.60^ 

Fever  resulted 11   "      8.39^ 

Total  duration  of  fever  in  11  cases  was  17  days;  average  duration,  one 
and  one-half  days. 

Of  102  cases  of  early  al)ortion  allowed  to  run  a  spontaneous  course, 
fever-free  puei']»('rium  resulted  in  all  1(>2  cases. 

TiK.MI.NATIoN    OF    9    CaSES    FkiJRILK    WIIKN     l^'l  ItST    SeEN. 

Cases. 
Snbj('ct(!d  to  iinmcdiato  curettage 8 

Allowed  to  run  a  spontaneous  course 1 

Of  the  8  curettage  cases,  fever  lasted  15 A  days  in  7  cases;  1  case  no 
record  ;  average  duration,  2  days. 


THE    PREMATURE   INTERRUPTION   OF    PREGN^VNCY.  197 


Late  Abortions. 

Of  88  cases  belonging  to  the  fourth  months  76  showed  no  febrile  symp- 
toms when  first  seen  by  the  Hospital  official,  12  showed  febrile  symptoms 
when  first  seen. 

Termination  of  76  Cases  JSTon-Febrile  when  First  Seen. 

Cases. 

Subjected  to  immediate  curettage 54 

Manual  extraction  of  the  placenta 7 

Allowed  to  run  a  spontaneous  course 15 

Total 76 

Cases. 

Fever-free  puerperium  resulted 72 

Fever  resulted 4 

Termination  of  the  12  Cases  that  were  Febrile  when  First  Seen. 

Cases. 

Subjected  to  immediate  curettage 12 

Allowed  to  run  a  spontaneous  course 0 

Of  the  curettage  cases,  fever  lasted  16^  days  in  12  cases;  average  dura- 
tion of  fever,  1.30  days. 

Of  37  cases  belonging  to  the  fifth  mo7ith,  36  showed  no  febrile  symp- 
toms when  first  seen  by  the  Hospital;  1  showed  febrile  symptoms  when 
first  seen. 

Termination  of  the  36  Cases  of  Fifth  Month,  ISTon-Febrile  when 

First  Seen. 

Cases. 

Subjected  to  immediate  curettage 1-1 

Manual  extraction  of  placenta  alone 3 

Allowed  to  run  a  spontaneous  course 19 

Total 36 


Of  the  immediate  curettage  cases,  fever  lasted  four  days  in  one  case. 

Termination  of  the  one  case  of  the  fifth  7nonth  that  was  febrile  when 
first  seen — subjected  to  immediate  curettage.  Fever  in  this  case  lasted 
four  days. 

Of  50  cases  belonging  to  the  sixth  month,  46  showed  no  febrile  symp- 
toms when  first  seen  by  the  Hospital.  Four  showed  febrile  symptoms 
when  first  seen. 


198  REPORT   OF   THE   SOCIETY   OF   THE    LYING -IX    HOSPITAL. 


Termixatiox  of  the  -iO  Cases  of  the   Sixth  Month,  Xox-Febkile  when 

First  Seen. 

Cases. 

Subjected  to  immediate  curettage 0 

IManual  extraction  of  placenta  alone 10 

Allowed  to  run  a  spontaneous  course 30 

Total 40 

Cases. 

Fever-free  ])uer]>erium  resulted 38 

Fever  during-  puerperiuni  resulted 8 

Termination  of  the  4  Cases  of  the  Sixth  Month  that  were  Febrile 

WHEN  First  Seen. 

Cases. 

Subjected  to  immediate  curettage 3 

Allowed  to  run  a  spontaneous  course 1 

Of  the  immediate  curettage  cases,  fever  lasted  3^  days  in  3  cases  ; 
average  duration,  1.13  days. 

Of  0  cases  of  interrupted  pregnancy  in  which  month  of  gestation  was 
unknown,  0  sliowed  no  febrile  symptoms  when  first  seen  by  the  Hospital. 
None  showed  febrile  symptoms  when  first  seen. 

Termination  of  the  0  cases  of  unknown  month,  non-febrile  when  first 
seen — sul^jected  to  immediate  curettage,  0. 

Of  tlie  primary  curettage  cases,  fever-free  puerperium  resulted  in  0 
cases;  fever  during  puerperium  resulted  in  0  cases. 

Resume  of  our  417  Caiita  of  Early  and  Late  Ahoj'tions,  toitli  Percentage 
of  Ties  nits. 

Of  the  total  417  cases,  388  showed  no  fel)rile  sym])toms  when  first  seen 
by  the  Hospital;  29  showed  febrile  symptoms  when  first  seen. 

Termination  of  the  388  Cases  that  were  Non-Febrile  when  First 

Seen. 

Cases. 

Subjected  to  immediate  curettage 203  or  48.08,^ 

Manual  extraction  of  placenta '25    ''  5.99j^ 

Expression  of  ])hicenta 17    ''  4.07j^ 

Not  noted 8    ''  1.91^ 

Allowed  to  run  a  s])ontaneous  course 135    "  32.37^ 

Total 388 

Of  the  immediate  curettage  cases,  fever  during  piici'iH^rium  resulted  in 
15  cases,  or  3.59ji^. 

Of  the  manual  extraction  of  tlio  ])hicenta  cases,  fever  (hiring  ])uer])e. 
rium  resulted  in  5  cases,  or  1.19^. 


THE   PREMATURE    INTERRUPTION    OF   PREGNANCY.  199 


Termination  of  the  29  Cases  that  Showed  Febrile  Symptoms  when 

First  Seen. 

Cases. 

•  Subjected  to  immediate  curettage 25  or  86.2^ 

Allowed  to  run  a  spontaneous  course -i    "    13.8^ 

Total  numl;)er  of  cases  out  of  the  417  abortions  that  were  non-febrile 
when  first  seen,  but  developed  fever  in  the  service  of  the  Hospital,  37. 

Table  of  Total  I^fmber  of  Cases  out  of  Our  417  Abortions  that 
Showed  Febrile  Symptoms  either  when  First  Seen  by  This  Hospital 
or  Subsequently,  with  Treatment. 

Xon-febrile  when  first  seen, 
Expectant  treatment, 
13  cases. 


66  cases  of  fever 
among  417  abor- 
tions, or  15.83^. 


8  cases. 
Febrile  when  first  seen, 
5  cases. 


Active  interference, 


^Non-febrile  when  first  seen, 
29  cases. 
53  cases.  ]    Febrile  when  first  seen, 

24  cases. 


Treatfuent  of  Sj^ontaneotis  Premature  Labor. 

The  treatment  of  spontaneous  premature  labor  in  our  service  has  prac- 
tically been  the  same  as  that  of  labor  at  term,  as  is  indicated  in  the  follow- 
ing table: 

Treatment  in  218  Premature  Labors. 

Cases. 

Instrmnental  curettage  only 6 

Digital  curettage  only 2 

Intrauterine  douche  only 27 

Expectant  treatment  purely 183 

Total 218^ 

Although  we  have  already  set  forth  under  Prognosis  the  manner  of 
placental  delivery,  still  we  give  the  table  here : 

Placental  Delivery  in  218  Premature  Labors. 

Cases. 

Spontaneous  deliver}'" 47 

Expressed 145 

Manually  removed 20 

No  record 8 

Total 220 

Regarding  the  apparently  large  number  of  placentae  manually  removed, 
it  must  be  remembered,  as  stated  in  another  place,  that  there  were  eight 
cases  of  placenta  prsevia  among  the  218  cases  of  premature  labor. 


200 


REPORT   OF   THE    SOCIETY    OF   THE    LVING-IN"    HOSPITAL. 


Fever  in  Ol'R  218  Cases  of  Spontaneous  Premature  Labor. 

Of  our  218  cases  of  s})(mtaneous  premature  labor,  the  histories  show 
febrile  symptoms  either  at  the  time  the  cases  Avere  first  seen  by  the  Hospi- 
tal officials,  or  subsoiiueiitly,  in  42  instances,  or  19.27'^.'. 

The  following  table  inilicates  the  causes  of  the  fever  in  these  -42  cases  : 

Causes  of  Fever  in  Spontaneous  Premature  Labor. 

Cases. 

Fever  due  to  sepsis 20  or  9.27j^ 

"  "     mastitis 4 

"  "     consti])ati()n 3 

*'  "     pneumonia 3 

"  "     mastitis  and  sepsis 2 

"  "     abscess  of  breast 1 

"  ''     tuberculosis  (pulmonary) 1 

"  "     eclampsia 1 

"  "     unknown  cause 7 

Total 42 

Tlie  following  table  indicates  the  duration  of  fever,  the  day  of  highest 
temperature,  and  cause  of  the  fever  in  the  42  cases  that  Avere  febrile  either 
Ijefore  or  after  being  seen  by  this  Hospital : 

Fever  in  Spontaneous  Premature  Labor. 


C.N. 


150 

161 

257 

311 

357 

388 

393 

418 

446 

657 

688 

885 

889 

942 

1.026 

1,308 

1,639 

1,723 

2,206 

2,573 

2,695 


Duration 

of 

Fever. 


30  days. 

12  " 

4  " 

2  " 

4  " 

1  " 

1  " 

6  " 

2  " 
2  " 
2  " 

1  " 

2  " 

1  " 

2  " 

1  " 

2  '• 

7  " 


1  day. 

2  " 


Day  of 

Highest 

Temp. 


2d  day. 

4th  " 

4th  " 

4th  " 

4th  " 

.•}d  " 

6tli  " 

4th  " 

:}d  " 

3d  " 

3d  " 

L.  " 

L.  " 

2d  " 

iHt  " 

3d  " 

r.tli  " 

7th  " 

4th  " 

4th  " 

3d  " 


Cause  of  Fever. 


Sepsis. 


Pneumonia. 
Unknown  cause. 
Mastitis. 
Pneumonia. 
Sepsis  &  Ma.stitis. 
Mastitis. 

Sepsis. 
Constipation. 

Sepsis. 

Sepsis  &  Ma.stitis. 

Sepsis. 

Pneumonia. 

Sepsis. 


C.N. 


3,030 
3,058 
3,324 
3,661 
3,854 
4,235 
4,800 
5,223 
5,357 
5,582 
5,945 
6.128 
6,148 
6,423 
6,880 
7,070 
7,167 
8,303 
8,643 
9,287 
9,753 


Duration 

of 

Fever. 


1  day. 
1     '' 
1     " 


2  days. 
2     "■ 
6     " 
2     " 
2     " 


1  day. 


1  day. 
4     " 


I  day. 
I     " 
1     " 
1     " 


Day  of 

Highest 

Temp. 


2d  day. 

1st  " 

1st  " 

L.  " 

2d  " 

1st  " 

2d  " 

5th  " 

4th  " 

5th  " 

3d  " 

7th  " 


1st  dav 

2d  ••■ 

2d  " 

L.  " 

3d  " 

4th  " 

4th  " 

3d  " 


Cause  of  Fever. 


Constipation. 
Unknown  cause. 
Sepsis. 

Unknown  cause. 
Abscess  of  breast. 
Sepsis. 


Mastitis. 

Phthisis. 

Simple  rise. 

Sepsis. 

Cause  unknown. 

S<'i)sis. 

Eclampsia. 

Sepsis. 

Cause  unknown. 

S(^l)sis. 

Unknown. 


Total,  42  casRH  of  ftivor.  or  10.27  per  cent,  of  218  cases. 


THE  PREMATURE  INTERRUPTION  OF  PREGNANCY. 


201 


Types    of    Early    and    Late    Aboktions    and    Spontaneous    Premature 
Labors,  with  Symptoms,  Treatment,  and  Results. 

Case  I. 

Earhj  ahoHloii ;  mistaken  diagnosis  ;  profuse  hcemorrhage  ;  digital  curet- 
tage^ followed  in  five  days  hy  instrumental  curettage ;  fever  hefore  latter 
curettage^  none  after  j  good  recovery. 

C.  N.  6,223.— Second  month  of  gestation;  first  seen  May  18tli;  thought 
at  this  time  to  be  a  case  of  complete  abortion ;  mistaken  diagnosis;  upon 
May  22d,  four  days  after,  a  profuse  haemorrhage  occurred,  which  thre^y  the 
patient  into  coUapse,  causing  her  to  lose  consciousness,  and  necessitating 
the  free  use  of  stunulants;  the  embryo  and  decidua  were  digitally  removed 
at  this  time;  upon  May  2Tth,  the  fifth  day  of  the  puerperium,  the  uterus 
was  thoroughh^  curetted  with  both  sharp  and  dull  curettes,  ether  being 
used,  and  a  quantity  of  foul- smelling  decidua  removed;  the  uterus  at  this 
time  was  packed  with  gauze ;  this  patient  suffered  from  persistent  headache 
throughout  the  puerperium  (syphilis  ?) ;  after  being  under  observation  for 
fifteen  days,  and  the  lochia  having  ceased,  the  patient  was  discharged. 


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203 


REPORT   OF   THE   SOCIETY    OF   THE    LYIXG-IN    HOSPITAL. 


Case  II. 

Incomplete  early  abortion;  louif-continved  hemorrhage;  sepsis;  curet- 
tage ;  good  recover ij. 

C.  i^.  781. — Incomplete  abortion;  third  montli;  duration  of  symptoms 
three  weeks;  profuse  hiemorrhage ;  temperature  when  first  seen,  103.5  de- 
crees; immediate  instrumental  cui-etta^e  and  uterine  irrigation;  tempera- 
ture immediately  after  operation,  103.2  degrees;  normal  temperature  and 
pulse  on  third  day  after  operation;  ])atient  left  her  l)ed  on  the  sixth 
day,  and  was  discharged  in  gootl  condition  on  the  seventh  day.  (See 
Tem])erature  Chart.) 


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Cask  IN. 

Early  inr.oraplete  abortion;  severe  hcemorrhage ;  hnmediate  curettage; 
metriti>f ;  subseqiient  labor  at  terra. 

C.  N.  1,153. — Third  montli  of  gestation;  one  ])reviouB  abortion;  first 
seen  by  the  Hospital,  December  31,  IsiM:  pati<'nt  at  this  time  was  very 
weak  from  uterine  hajmorrhagc;  wlndi  li:i<l  coiiliniicd  foi-  foin-djiys;  history 
of  an  incomi)l(!U!  abortion  two  <lays  previous;  tempei-itiu'c;  when  seen, 
101.2  degrees;  ])ulse,  llo;  os  admits  oidy  one  fing(!i';  immediate  instru- 
mental curettage;  pieces  of  (lc(i(lii;i  rriiio\('(l;  siil)liinate  iit(^i'ine  irrigation ; 


THE    PREMATURE    IXTERRUPTION    OF    PREGNANCY. 


203 


temperature  aftei-  operation,  lul. 4  degrees;  pulse,  112;  painful  uterus  on 
first  and  second  days;  foul  lochia  on  fourth  day;  uterine  irrigations  on 
first,  second,  and  fourth  days;  bowels  acted  onireely  with  Epsom  salts; 
sthnulated  with  whiskey  and  given  quantities  of  milk  because  of  anaemic 
condition;  discharged  on  sixth  day.     (See  Temperature  Chart.) 

This  ]3atient  was  subsequently  delivered  of  a  living  child  at  term.     No 
history  of  subsequent  interrupted  pregnancies. 


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Case  IY. 

Incomplete  late  cibortion ;  sepsis;  iwofxise  licemorrhage ;  curettage; 
syphilis  ;  cardiac  disease. 

C.  N.  3,803. — Month  of  gestation,  third  and  one-half;  when  first  seen, 
temperature,  101.2  degrees ;  pulse,  110 ;  foetus  had  come  away  half  an  hour  be- 
fore, accompanied  by  profuse  hiemorrhage;  placenta  was  found  plugging  the 
OS,  which  latter  admitted  two  fingers  readily ;  placenta  w^as  removed  by  digi- 
tal traction;  uterus  curetted  instrumentallv,  and  uterine  sublimate  douche 


204 


REPORT   OF   THE    SOCIETY   OF   THE    LYING-IX    HOSPITAL. 


given;  very  little  lia?inorrbiige  after  operation;  twenty -four  hours  after 
operation,  temperature,  100,0  degrees;  pulse,  10i2.  This  ease  was  suffering 
at  the  time  from  syphilis,  with  ulceration  in  the  fauces. 

Chronic  cardiac  disease  and  emphysema  were  also  present  in  this  case 
as  complications.  V\Mm  the  third  day  of  the  pueri)ei'ium  the  patient 
refused  further  treatment,  and  was,  consequently,  discharged. 


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Case  V. 

Late  abortion  ;  sepsis  ;  profuse  hmmoi'rhage  ;  periuterine  injUmimation  ; 
curettafje  /  partial  rcrovery. 

C.  X.  1,177. — Fourth  month  of  gestation;  lii-st  seen  .lanuaiy  4,  1892, 
by  this  IIos))ital;  liistory  at  this  tim(>  of  uterine  h{i}morrhage  for  several 
days  past,  for  whicli,  two  days  ])reviou.sly,  vagina  had  he(!n  t;ini])on("(l  hy  a 
j)rivat€  physician;  when  Jirst  seen,  temperature,  1()4  degrees  Fahrenlieit; 
pulse,  120;  no  lia>morrhage;  hot,  <hy  skin;  hejuhulM-  tympanitis;  abdoin- 


THE   PREMATURE   INTERRUPTION    OF   PREGNANCY. 


305 


inal  pain  and  tenderness;  pain,  tenderness,  and  swelling  in  left  broad 
ligament ;  vagina  filled  with  foul-smelling  clots ;  os  the  size  of  a  five-cent 
piece.  Treatment  consisted  in  cleansing  vulva  and  vagina,  thoroughly 
curetting  uterus  with  sharp  curette,  and  irrigating  with  j-^^  sublimate 
solution,  applying  hot  applications  over  abdomen,  and  in  administering 
calomel,  one-half  grain  every  half  hour  for  four  doses. 

Much  foul-smelling  dehris  was  removed  from  the  uterus,  and  the  tem- 
perature and  pulse  after  operation  were  lOtt  degrees  and  106  respectively. 


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Uterus  remained  very  sensitive  for  eight  days;  slight  discharge  after 
operation;  abdominal  tenderness  and  tympanitis  continued  for  three  days; 
tongue  remained  coated  for  five  days,  then  cleared;  well-marked  parame- 
tritis and  vaginitis  (gonorrhoeal?). 

The  bowels  were  fully  moved  after  the  calomel  with  salts ;  morphine 
was  given  for  the  severe  pain,  and  the  patient  was  supported  with  quinine, 
whiskey,  and  milk. 

Patient  discharged  on  ninth  day,  the  parametritis  in  left  broad  liga- 
ment still  giving  some  pain. 


206 


REPOKT   OF   THE   80C1ETV    OF   THE    LVING-IN    HOSPITAL. 


Case  VI. 

Late  abort  ion  ;  incomplete',   acute  sepsis ',  moderate  hoBmorrhage  ;  curet- 
tage; cessation  of  fever  ;  aJhuminuria. 


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C.  N.  2,755. — Montli  of  gestation,  fiftli  and  one-lialf;  wlion  first  seen, 
temperature,  lo4.<;  degrees;  pulse,  120;  ineoinplete  id)ortion  with  retained 
and  adherent  ])hicenta;  moderate  haemorrhage;  placenta  was  immediately 
e.xtracted  manually,  and  in  so  doing  was  broken  up  into  many  ])ieces; 
uterine  suljlimate  douche  was  tiien  given;  the  temperature  chart  shows  that 
the  fever  continued  Un-  foui-  days,  and  that  the  lochia  was  foul  u])on  the 
tliird  and  fourth  days;  u])on  the  fourth  day  of  the  ))uer))erium  insti-innental 
curettage  wa,s  perfornuxl,  and  several  small  pieces  of  ])lacental  tissue  re- 
movetl  from  the  uterine  cavity.  As  will  be  seen  in  the  accompanying  chart, 
there  was  jjractically  my  f(;ver  after  the  curettage;  the  curettage  was 
followed  l)y  the  usual  sublimate  uterine  douche;  albimiinuria. 


THE   FKEMATURE   INTERRUPTION    OF   PREGXAjSCY. 


207 


Case  VII. 

Late  abortion  ;  long-continued  hcemorrhage  j  uterine  douche  j  otherwise 
expectant  treatment. 


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C.  IN".  4,198. — Abortion,  sixth  month;  symptoms  began  ten  clays  before 
being  seen,  at  which  time  an  abortion  was  threatened;  in  addition  there 
was  a  history  of  an  intermittent  haemorrhage  for  seven  weeks  previous ; 
when  first  seen  by  the  Hospital  the  foetus  was  found  presenting  at  the  os 
uteri ;  a  vaginal  tampon  was  applied  for  one  and  a  half  hours ;  at  the  end 
of  that  time  foetus  was  expelled  and  placenta  came  away  spontaneously, 
but  broken  up  into  several  pieces ;  duiration  of  third  stage  was  ten  minutes ; 
foetus  was  hydrocephalic  and  placenta  markedl}"  fatty;  no  curettage;  single 
rise  of  temperature  (101.8)  on  first  day;  at  this  time,  also,  a  single  piece  of 
placenta  was  expelled ;  the  membranes  were  incomplete,  the  retained  por- 
tions being  subsequently  found  in  the  vagina;  we  beHeve  this  fever  was  of 
septic  origin ;  there  were  no  mammary  symptoms,  nor  tenderness  of  uterus. 


208 


REPOKT   OF   THE   SOCIETY    OF   THE    LVING-LN    HUSFITAL. 


Case  YIII. 

Early  abort  ion ;  profuse  hcemorrhage  •  digital  curettage  and  smooth 
curette;  jjeriuterine  inflammation ;  fever  for  eleven  days ;  labor  at  term^ 
fourteen  months  after. 


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been  present  for  eight  days,  ;iinl  i^'olusc  Jia-mon-luigefoni  lew  hours  pi-cvi- 
ous  to  hoing  seen  by  tliis  Hospital;  ovmn  was  loiuid  in  tho  os  and  removed, 
the  uterus  then  Ijeing  curetted  diiiitally  and  with  smooth  cui-cttc;  tliis  Avas 
followed  by  the  usual  intrauteriiii' < louche;  on  the  foiirlh.  lifth,  sixlli.  and 
seventli  days  of  the  puerpoi-inm,  ah(h)iii(Mi  was  tciuhM-  to  ])ressuro  and  tym- 
panitic; fr('(;  catharsis  and  hot  applications  to  the  abdomen  nsi^d :  on  the 
nintli  day  pain  and  tenderness  is  recorded  in  Itoth  Fallopian  tubes;  tem])er- 
ature  reached  nontial  ])ointon  twclt'th  day;  no  fever  tluM'eaftei-.  no  uterine 
treatment  was  used  after  tlie  curettage;  patient  discharged  on  the  sixteciuth 
day,  in  only  fair  condition,  there  being  sym])toms  at  this  liuu'  of  j)ara- 
metritis. 

This  patif'Ut  was  delivci-ed  of  a  living  child  at  term,  rourtceii  inoiiths 
(August,  la'M)  after  the  fonjgoing  abortion. 


THE   PKEMATUKE    INTERRUPTION   OF   PREGNANCY.  209 

Case  IX. 

Premature  labor  ;  mo rhid  adhesion  of  jjlacenta  ;  fever  ;  manual  extrac- 
tion of  placenta  J   oureitaye  ^  '_pa7'ametTitis. 


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ond stage  of  labor,  which  lasted  nine  hours;  temperature  when  seen,  101.2 
degrees;  pulse,  107;  placenta,  adherent  and  markedly  fatty,  was  torn  in  the 
manual  extraction ;  duration  of  third  stage,  thirty  minutes ;  pieces  of  pla- 
centa left  in  uterus  digitally  removed  as  far  as  possible ;  twentj^-f our  hours 
later  temperature,  103  degrees ;  pulse,  120 ;  chloroform ;  external  genitals  and 
vagina  cleansed  with  lysol  (5  per  cent.)  and  sublimate  solution  (ro'Fo)j 
uterus  curetted  with  dull  curette ;  pieces  of  placenta  and  membranes  brought 
away;  uterus  irrigated  with  sublimate  solution  (yoto^)  ^^^  packed  with 
gauze;  chill  immediately  after  operation ;  temperature,  104  degrees;  pulse, 
120 ;  temperature,  101  to  103  degrees  for  four  days ;  gauze  removed  on  second 
day;  examination  showed  uterus  bound  down,  and  parametritis;  no  foul 
lochia ;  discharged  on  tenth  day ;  culture  from  uterus  showed  absence  of 
organisms  before  operation.  (See  Bacteriology.) 
14 


210  REPORT   OF   THE   SOCIETY    OF   THE    LYING-IN    HOSPITAL. 


BiBLIOUKAPHY. 

1.  Ahlfeld:  Archiv  f.  Gyniikologie,  viii.,  p.  194. 

2.  Winckel:  Text-book  of  :Mi(l\viforv,  rhila(lel])liia,  1890,  p.  51. 

3.  Stumpf :   Miincliener  mediciiiische  AVoc-bonsehrift,  1S8S,  p.  403. 

4.  Chailly:  Practical  Treatise  on  ]\[idwirerv.  Am.  edition,  1846. 

5.  ^[aunsell:  Dublin  Practice  of  ]\[id\viferv,  Am.  edition,  1842. 

«'..  Cliuivhill:  On  the  Theory  and  Practice  of  Midwifery,  Am.  edi- 
tit>n.  {>''>''>. 

7.   Haushalter:  Arcliives  de  Tocologie,  1890,  xvii. 

S.  De  Marbaix:    La   CeUule,   1892,   Yiii. ;    Fortschritte   der   Medicin, 
1893.  No.  5. 

II.   AVidal:   Bulletin  de  FAcad.  de  Med.,  1888,  xix. 
Iti.   Punim:  Centralbl.  f.  Gyniik.,  1892,  No.  9. 

11.  Gartner:  Archiv  f.  Gyniik.,  xliii. 

12.  Fritsch:  Deutsche  med.  "Wochenschr. ,  1891,  xvii. 

1:k  Williams:  Aincr.  Journ.  of  Med.  Sciences,  July,  1893. 

14.  Si))i)L'll:  Deutsch.  med.  Wochenschr.,  1894,  No.  52. 

15.  AVilliams:  Johns  Hop.  IIosp.  Reports,  1892,  vol.  iii. 

16.  Cullen:  Johns  IIoj).  TIosp.  Eeports,  1895,  vol.  iv.,  Nos.  7  and  8. 

17.  Diihrssen  :  Archiv  fiir  GyniikoL,  xxx.,  161,  1887. 

18.  Schroeder:  Lehrbuch  der  Geburtshilfe. 

19.  Spiegelberg:  Lehrbuch  der  Gelmrtshilfe. 

21.  Klein:  Zeitschrift  f.  Geb.  u.  Gyniik.,  bd.  xxii.,  p.  247. 

22.  Ekstein:  Prager  Med.  Woch.,  Nos.  xvi.,  xvii.,  1892. 

23.  Kiirstner:  Arch.  f.  Gyn.,  xviii. 

24.  Fritsch:  Handb.  f.  Frauenk.,  i.,  p.  980. 

25.  Schroeder:  Handb.  der  Krankh.  des  weib.  Korpers,  1886. 

20.  AVinckel:   Lehi'buch  d.  Frauenk.,  1880. 

27.  Porak:   Pul.  et  mem.  de  la  Soc.  Obstet,  et  Gynecol,  de  Paris,  1889, 
p.  1 '.»:.. 

28.  Lehmann:  Berlin  klin.  AVochen.,  June  25,  1894. 

29.  Hirschfeld   and    Schmorl:    Prit.    Med.    Journ.,    abstract,   June  6, 
1891,  ])ar.  5(i5. 

30.  Mornnv's  "  System  of  Genito-Urinavy  Diseases,  Syphilology,  and 
Dermat<;logy,""  vol.  ii.,  p.  269. 

31.  Hehrer:   Archiv  fiir  Gyniik.,  vol.  xlv.,  pt.  3,  1894. 

32.  Priestly:   Liiiiil(i;iii  Lectures,  p.  88. 

33.  "Williams:  .loliiis  Hop.  IIosp.  Reports,  a'oI.  iv.,  No.  9. 

34.  .M<-ng(':  Zcit.  f.  (icb.  u.  (iyii.,  xxx.,  323-305,  1S95. 

35.  Matthews  Duncan:   Lancet,  Oct.  30  and  Nov.  0,  1880. 
30.   AhllVld:  Zcit.  f.  TJcb.  u.  Gyniik.,  1S93,  bd.  xxvii.,  lit.  2. 

37.  P>unini:    .\ivliiv  f.  (Jyniik.,  IM)!,  bd.  xl.,  lit.  3. 

38.  von  l''ran(|ii«'-:  Zcit.  f.  (ieb.  u.  (tVU.,  1S93,  xxv.,  p.  277. 

39.  WilliaiM.s:   Anier.  Jouni.  of  :\Ied.  Sci.,  July,  1893. 

40.  Mayrliofei-:    Monatssdi.  f.  ( icbiirtslcinide,   iSfir),  xv.,  ]).  112. 


THE    PREMATURE    INTERRUPTION    OF    PREGNANCY.  211 

41.  Pasteur:  Comptes  Rendus  cles  Seances  de  I'Acad.,  18S0,  p.  1038. 

42.  Doderlein:  Arch.  f.  Gyn.,  1891,  xL,  p.  99. 

43.  KOiiig:  Centralblatt  f.  Gyniik.,  Feb.  25,  1893. 

44.  Flexner:  Bulletin  of  Johns  Hopkins  IIosp.,  1893,  p.  12. 

45.  Ileyse:  Deutsche  med.  Wochenschrift,  1893,  ISTo.  14. 

40.  Semmelweiss :  "  yEtiologie,  Begriff  und  Prophylaxisdes   Kindbett- 
fiebers,"  Buda.,  Wien,  Leipzig,  1861. 

47.  Doderlein:   "  Das  Scheidensekret, "  Leipzig,  1892. 

48.  Mermann:  Centr.  f.  Gyniik.,  1893,  p.  177. 

49.  Leopold:  x\rchiv  f.  Gynak.,  1891,  xL,  p.  439. 

50.  Doderlein:  Archiv  fiir  Gynak.,  xxxi.,  1887,  p.  412. 

51.  Bumni:  Centralblatt  f.  Gynak.,  1892,  No.  9. 

52.  Rindfleisch:  Lehrbuch,  Ite  Aufl.,  p.  204. 

53.  Recklinghausen:  Centralbl.  f.  med.  Wissenschaften,  1871,  p.  713. 

54.  Waldeyer:  Arch.  f.  Gynak.,  1872,  iii.,  p.  293. 

55.  Klebs:  Arch.  f.  exper.  Path.,  bd.  v.  p.  417. 

56.  Orth:  Virchow's  Archiv,  Iviii.,  p.  441. 

57.  Spillman:  Zeit.  f.  klin.  Med.,  1880,  p.  408. 

58.  Friinckel,  quoted  by  Lomer:  Zeit.  f.  Geb.  u.  Gyn.,  x.,  366. 

59.  Winckel:  Yerh.  d. '^Deutschen  Ges.  f.  Gyn.,  1886,  p.  78. 

60.  Bumm:  Centralbl.  f.  Bacter.,  1887,  ii.,  p.  343. 

61.  Winter:  Zeit.  f.  Geb.  u.  Gyn.,  1888,  xiv.,  p.  443. 

62.  Brieger:  Charite-Annalen,  1888,  xiii. ,  p.  198. 

63.  Czerniewsky:  Archiv  f.  Gynak.,  1888,  xxxiii.,  p.  73. 

64.  Fehling:  Yerhand.  Deut.  Ges.  f.  Gyn.,  Freiburg,  1889. 

65.  Hagler,  quoted  by  Fehling:    "  Phys.   u.   Path,  des  Wochenbetts," 
Stuttgart,  1890. 

66.  Kuliscioff :  Gazetta  degli  Ospitali,  1886,  N"o.  77. 

67.  Kehrer:  Miiller's  Handbuch  der  Geburtshiilfe,  1888,  i.,  p.  545. 

68.  Kaltenbach:  Yer.  d.  Deutschen  Ges.  f.  Gynak.,  Freiburg,  1889. 

69.  Gonner:  Centralbl.  f.  Gyn.,  1887,  p.  444. 

70.  Thomen:  Archiv  f.  Gyn.,  1889,  xxxvi.,  p.  231. 

71.  Widal:  Gaz.  des  Hop.*^,  1889,  p.  565. 

72.  Witte:  Zeit.  f.  Geb.  u.  Gyn.,  1892,  xxv.,  p.  8. 

73.  Bossowsky:  Wiener  med.  Wochen.,  1887,  I^os.  8  and  9. 

74.  Welch:  Amer.  Journ.  Med.  Sci.,  ISTov.,  1891. 

75.  Kronig:  Deutsche  med.  Wochenschr.,  1894,  I^o.  43. 

76.  Bumm:  Lancet  (N.  Y.),  1895,  Iso.  8,  p.  263. 

77.  Menge:  Lancet  (N.  Y.),  1895,  No.  8,  p.  266. 

78.  Hofmeier:  Miinchener  med.  Wochenschr.,  1894,  No.  42. 

79.  Yahle:  Zeitschr.  f.  Geburts.  u.  Gyn.,  bd.  xxii.,  ht.  3. 

80.  Walthard:   Archiv  f.  Gyn.,  bd.  xlviii.,  ht.  2. 

81.  Wertheim:  Centralblatt  f.  Gynak.,  1895,  No.  26,  p.  699. 

82.  Brion:  Etude  critique  sur  530  cas  d'avortement,  G.  Steinheil,  Paris, 
1892. 

83.  Misrachi:  Nouvelles  Archives  d'Obstet.  et  de  Gyn.,  1889,  pp.  195, 
497. 


212  REl'ORT   OF   THE   SOCIETY    OF   THE    LYING-IX    HOSriTAL. 

S4.  Leopold :  Beitnige  ziir  Yerhiitimg  des  Kindbettliebers.  Deutsche 
meii.  Wochensohrift,  Xo.  !25,  1887;  Xo.  20,  1888. 

85.  8tiiin})f:   Munclioiior  med.  AVocheiischrift,  1888,  p.  463. 
S6.  Porak:  l^ull.  et  uu'iii.  do  la  Soc.  Ohst.  et  Gynec.  de  Paris. 

87.  Rochet:  Traiteiueiit  deravorteiuent  incomi)let.  Joiirn.d'accouche- 
ments,  Lit-ge.  181)2,  xii.,  pp.  109,  181. 

88,  Goldschiuidt:  These  de  Strassboiirg,  1854. 

80.  Enge:  Zur  ^Etiologie  und  Anatomie  der  Endometritis.  Zeitschr. 
f.  Geb.  und  Gyn.,  v.,  h.  2. 

00.  Olshausen:  UebiT  cliron.  hy]>erplas.  Endometritis  des  Corpus 
Uteri.     Arch.  f.  Gyn.,  vii.,  p.  121. 

01.  Bischotf :  Die  sog.  Endom.  fungosa.  Correspondenzbl.  f.  Schweizer 
yErzte,  1878. 

02.  Brennecke:  Zur  ^Etiologie der  Endometr.  cet.  Arch.  f.  Gyn.,  xx., 
p.  455, 

03.  Diihrssen:  Zur  Pathologic  und  Tlierapie  des  Abortus.  Arch.  f. 
Gyn.,  1887,  xxxi.,  ]).  KU. 

04.  Fritsch:  Die  Krankheiten  der  Frauen,  Berlin,  1889,  p.  226. 

05.  Henricius:  Ueber  die  chron.  hyperpl.  Endometr.  Arch.  f.  Gyn., 
xxviii. 

9t;.  ^lartin:  Pathologic  u.  Therapie  der  Frauenkrankheiten,  Wien  u. 
Leipzig,  lss7,  p.  2o4. 

97.   Kiistner:  Beitriige  zur  Lehre  von  der  Endom.,  Jena,  1883. 

08.  Pu]i|'>e:  Untersuchungen  uber  die  Folgezustande  nach  Abortus. 
Inaug.  Dissert.,  Berlin,  1890. 

99.  Bibot:  Arch,  de  TocoL,  Xo.  5,  1894. 

100.  Lepage:  Precis  d'oljstetrique,  Paris,  1893. 

101.  Yeit:  Miiller's  Ilandbuch  der  Geb.,  bd.  ii.,  p.  54. 

102.  Winter:  Centralblatt  f .  Gyn.,  1890,  p.  111. 

103.  Klein:  Zeitsclirif t  f.  Geb.  u.  Gyn.,  bd.  xxii.,  ]>.  247. 

104.  Boetus:  Centralblatt  f.  Gyn.,  1877,  p.  352. 

105.  Czobos,  Karl:  Zur  Behandlung  des  Abortus.  Central))],  f.  d. 
gesammte  Therapie,  Vienna,  1884,  ii.,p.  529. 

100.  Sclnvarz,  E. :  Zur  Behandlung  der  Fehlgeburt.  Samml.  klin. 
Yortr.,  Gyniik.,  p.  241,  1884,  Leipzig. 

107.  AVeekbecker-Sternfeld :  Ueber  die  Anwendung  des  scharfen  Loffels 
in  der  Geburtsliiilfe.     Arch.  f.  Gyn.,  Berlin,  1882,  xx.,  p.  230. 

1<»8.  Diihrssen:  Zur  Pathologic  und  Therapie  des  Abortus.  Arch.  f. 
Gyn.,  XXXV.,  ]>.  101,  Berlin,  1887. 

1(»9.   AVinckcl:  ^Muncliencr  med.  Wochonschr.,  1888,  p.  463. 

110.  Stiiiiipf:  Zur  .Kliologie  u,  Beliaiidhmg  der  Fehl-  u.  Friihgeburt. 
^liindi.  iii<(l.  Woclienschr.,  1892,  Nos.  43  and  44. 

111.  ZwcilVl:   LeliH)Ucli  dor  Gc]).,  ISSO. 

112.  Auvard:  Cas  d'avortcment  oil  le  cni'age  de  ru(('rns  ctait  seul  de 
Kiuvor  la  femme.  Arch,  de  TocoL,  Paris,  .Ian.,  isito,  |).  ci. — Avortement 
de  <|Uatro  niois  caus«*  ])ar  une  lu'inorrliagic;  utt'-i-iplaccntairc;  hrmorrlmgie 
dm-  vraiseniblablcinent  a  un  traumatismc  indirect.     Arch.  d.  TocoL,  Paris. 


THE    PREMATURE    INTERRUPTION    OF    PREGNANCY.  213 

1887,  p.  lUoO.  Also  Uull.  et  iiieiii  cle  la  Soc.  Obst.  et  Gynec.  de  Paris, 
1887,  p.  258. — Avortement  due  n  une  excitation  reflexe  provoquee  par  un 
ascaride.     Gaz.  hebd.  de  med.  et  de  chirur.,  Paris,  1878,  p.  754. 

113.  Brehm,  II.  von:  Ein  casuistischer  Beitrag  zur  Ilmgehung  der 
kiinstlichen  Friihgebnrt.  St.  Petersburger  med.  Wochenschr.,  1890,  No. 
9,  p.  77. 

114.  Prochownik:  Yolkmann's  Samml.  klin.  A'ortr.,  1881,  No.  3. 

115.  Spondly:  Zeitscbr.  f.  Geb.,  ix.,  1893. 

IIG.  Yoltz:'CentralbL  f.  Gyn.,  No.  52,  1883,  p.  835. 

117.  Charles.  N. :  De  la  delivrance  dans  I'avortement.  Journ.  d'ac- 
conchements,  Liege,  1890,  xi.,  p.  77. 

118.  Porak,  M. :  Prolapsus  de  I'uterus  et  Allongement  hypertrophique 
du  col  compliquant  la  grossesse ;  avortement  au  4e  mois ;  retention  du  pla- 
centa; delivrance  artiiicielle.  Bull,  et  mem.  Soc.  Obst.  et  Gynec.  de  Paris, 
1891,  p.  7. 

119.  Audebert:  De  rintervention  dans  I'infection  puerperale  post- 
abortive.    Arch,  de  TocoL,  Paris,  1890,  xvii.,  No.  9,  p.  651. 

120.  Winckel:  Miincli.  med.  Wochenschr.,  1888,  p.  463. 

121.  Stumpf:  Miinch.  med.  Wochenschr.,  1892,  Nos.  43  and  44. 

122.  "Winter:  Zur  Behandlung  des  Abortus.  Beilage  zum  Centralbl. 
f.  Gyn.,  Leipzig,  1890,  xiv.,  p.  111. 

123.  Tarnier:  De  la  delivrance  dans  Tavortement.  Revue  pratique 
d'obstet.  et  de  pediatric,  Dec,  1892,  p.  353,  and  Jan.,  1893,  pp.  1, 
33,  97. 

124.  Boetus:  Zur  Behandluno- der  Blutuno^en  nach  Abort.  Centralbl. 
f.  Gyn.,  Leipzig,  1877. 

125.  Fehling,  H. :  L'eber  die  Behandlung  der  Fehlgeburt.  Arch.  f. 
Gyn..  Berlin,  1878,  xiii.,  p.  222. 

126.  Hartwig,  Marcell:  Znr  Behandlung  des  Abortus.  New  Yorker 
med.  Presse,  1885-1886,  i.,  p.  243.— Hoav  Shall  We  Manage  Abortion? 
Buffalo  Med.  and  Surg.  Journ.,  1885-1886,  xxvi.,  p.  241. 

127.  Felseureich:  Die  Auskratzuno-  des  Uterus  zur  Entfernuno-  von 
Eiresten.     AUg.  Wiener  med.  Zeitung,  1885,  xxx. ,  p.  499. 

128.  Moses:  Einundsechzig  Fiille  von  Abort  aus  der  geburtshilflichen 
Universitats-Poliklinik  zu  Breslau,  mit  Bemerkungen  liber  ^Etiologie, 
Symptomatologie  und  Therapie.  Inaug.  Dissert.,  Breslau,  1884. — Cen- 
talbl.  f.  Gyn.,  Leipzig,  1884,  viii.,  p.  272. 

129.  Braun,  C.  Y. :  Abortus  mit  Yerbleiben  der  Placenta  im  Litems; 
consecutive  Blutungen.     Allg.  Wiener  med.  Zeitung,  Dec,  1882,  p.  534. 

130.  Pick,  P. :  Ueber  die  Anwendung  des  scharfen  Loffels  in  der  Geb- 
urtshiilfe,  vornehmlich  bei  Blutungen  post  Abortum.  Deutsche  med. 
Woch.,  Berlin,  Dec,  1883,  ix.,  No.  50,  p.  732. 

131.  Schvrarz,  E. :  Zur  Behandlung  der  Fehlgeburt.  Centralbl.  f.  d. 
ges.  Therapie,  Wien,  1884,  ii.,  p.  529.— Sammlung  klin.  Yortr..  Leipzig, 
1884,  p.  1715. 

132.  Dahlmann.  Franz:  Zur  Behandlung  der  Fehlgeburten.  DerFrau- 
enarzt,  1886,  i.,  p.  113. 


214  REPORT   OF   THE    SOCIETY    OF   THE    IA'INCt-IX    HOSPITAL. 

133.  Diihi-ssen,  A. :  Zur  Patbologie  iind  Tlierapie  "des  Abortus.  Arch, 
f.  Gyn..  Berlin,  ISST,  xxxv..  p.  101. 

134.  Dodorlein,  AlbtM't:  Die  Bebandhmg  der  inutungen  bei  Abortus, 
Placenta  prcevia  uud  Atouia  Uteri  postpartum.  Miincli.  ined.  Wochenscbr. , 
May,  1S02.  xxxix..  No.  lHi,  p.  339. 

135.  Eckstein,  Eniil:  Zur  Behandlung  der  Feblgeburt.  Prager  med. 
Wochenschr.,  1892,  xviii.,  Xos.  IC,  17.  pp.  177-186. 

130.  Bonifield,  C.  L. :  The  Treatment  of  Abortion.  Amer.  Journ. 
Obst.,  isiti\  XXV.,  p.  49. 

137.  Locke,  H.  G. :  The  Treatment  of  Incomplete  Abortion  at  Roosevelt 
Hospital.     ]^[ed.  Record,  Xew  York,  lSit2,  xli.,  p.  78. 

138.  Kuppenheim,  Rudolf:  Zur  Thera])ie  des  Abortus.  Deutsche  med. 
Wochenschr.,  Leipzig  u.  Berlin,  Dec,  1891,  p.  14*23. —Centralbl.  f.  Gyn., 
1892,  xiv. 

139.  Chaleix,  !Maxime:  Curage  digital  de  T uterus  dans  un  cas  d'hemor- 
rhao-ie  o-rave  consecutive  a  un  avortement  de  trois  mois.  Arch,  de  TocoL, 
Paris,  1891,  xviii.,  p.  14. 

140.  Bibot,  M. :  Contribution  a  Tetude  du  traitement  de  Tavortement 
embryonnaire.     Societe  beige  de  Gyn.,  Bulletin,  1893,  iv.,  p.  147. 

141.  Goltz,  von  der:  Zur  Behandlung  des  frischen  Abortus.  Medicin. 
Monatsschr.,  Xew  York,  1889,  i.,  p.  305. 

142.  Borel:  Du  curettage  uterin  dans  les  accidents  consecutifs  a  I'ac- 
couchement  et  a  la  fausse  couche.     Arch,  de  TocoL,  1890,  xvii.,  p.  89. 

143.  Kiistner,  Otto:  Decidua-Retention ;  Deciduom;  Adenoma  Uteri. 
Arch.  f.  Gyn.,  Berlin,  1881,  xviii.,  p.  252. 

144.  Charles:  Journ.  d'accouchements,  Dec,  1891. 

145.  Braun-Fern\vald,  Egon  V. :  Zur  modernen  Therapie  des  Abortus. 
Allg.  Wiener  med.  Zeitung,  1890,  xxxv.,  p.  4s3. 

140.  Lauros,  K.  X.:  Behandlung  der  Xachgeburtsperiode.  Allg. 
AVienermed.  Zeitung,  1892,  xlvii.,  pp.  537-548,  501-590. 

147.  Stratz:  Xederlaudsch  Tijdschrift  voor  Geneeskunde,  1x1.  xxix., 
b.  5,  0. 

148.  Demelin :  Traitement  de  la  retention  de  I'arriere-faix  dans  I'avorte- 
ment  au  3e  et  au  4e  mois  de  la  grossesse.  Revue  gen.  de  clinique  et  de 
Thera])euti(jue,  1889,  iii.,  p.  375. 

149.  Velitz,  II.:  l>eitrjige  zur  Frage  der  ]^>e(leutung  und  Therapie  von 
zuriickgebliebenen  Kihautresten.  Internationale  klin.  Rundschau,  Mar. 
8,  IV.H,  v.,  p.  400. 

150.  Doleris,  J.  A.:  ("onduite  a  tenir  dans  I'avortement;  curage  et 
ecouvillonage  de  ruterns  ])our  I'extraction  du  ])lacenta  retenu  dans  la  mat- 
rice.  Xouv.  Arch.  (FObst.  et  de  Gyn..  Paris,  issO,  ])p.  1,  282,  318.— lluit 
cas  d'avortements,  traites  par  la  dilatation  i-a|)i(l('  <hi  col,  le  curage  de  la 
iiiatrice,  h-s  in j<*ctionsantisepticjues.  Ann.  <l('(iyn.,  Paris,  ISSO,  xxv.,  p.  300. 

151.  Misrachi,  AI. :  A  i)rf)]X)s  du  ti-aitenu^nt  de  Favortement  par  hi 
quinine.  Annales  de  Gyn..  Fails,  Isss.  xxx.,  p.  120.  — Fn  dernier  mot 
sur  le  triitement  (hi  Favortement  incomplet.  Xouv.  Arch.  (l'()l)st.  et  (hi 
Gvn..  F^^l>.  iv..  1).  497. 


THE    PREMATURE    INTERRUPTION    OF    PREGNANCY.  215 

152.  Porak:  Bull,  et  mem.  de  la  See.  Obst.  et  Gyn.  de  Paris,  1889,  p. 
195. 

153.  Annschat:  ]\[ittheiliing-en  aiis  der  Praxis:  zur  Behandlung  des 
Abortus.     Deutsche  ]\[edizinal-Zeitung-,  Berlin,  1885,  No.  4,  p.  512. 

154.  Balin,  J.:  Ein  Fall  von  '"Missed  Abortion."  Centralbl.  f.  Gj^n., 
Leipzig,  1890,  xiv.,  p.  237. 

155.  Batuaud,  J.:  Tlierapeutique  de  Tavortement.  Gaz.  de  Gyn,, 
Paris,  1887,  ii.,  p.  110. 

15().  Bloch:  Ueber  die  Behandlimg  von  Metrorrhagien,  bedingt  durcli 
Retention  von  Abortusresten,  Centralbl,  f,  d.  gesammte  Therap,,  Wien, 
1888,  p,  193, 

157.  Brannan,  John  W. :  The  Treatment  of  Retained  Secundines  after 
Abortion.     Boston  Med.  and  Surg.  Journ.,  1884,  ex.,  p.  147. 

158.  Budin,  P. :  Eclampsie  au  septieme  mois  de  la  grossesse  chez  une 
multipare;  guerison  de  la  mere;  mort  de  P enfant  48  heuresplus  tard;  expul- 
sion d'un  oeuf  complet,  cinq  semaines  apres  la  mort  du  foetus.  Le  prog, 
med.,  2e  serie,  t.  iv.,  iS'o.  37,  Sep.  11,  1886,  p.  755.— On  the  Mode  of  Con- 
duct in  a  Case  of  Retention  of  Placenta  after  Abortion.  Transl.  fr.  Le 
Prog.  med.  by  Dr.  W.  H.  Wenning,  N".  C.  Med.  Jour.,  Mar.,  1887, 
19,  20. 

159.  Bureau:  Dangers  de  I'intervention  prematuree  dans  un  cas  de 
retention  placentaire  (avorteinent  de  3  mois  et  demi).  Jour,  de  med., 
Paris,  April  3,  1892,  p.  175. 

160.  Cecil,  John  G. :  Management  of  the  Secundines  in  Abortion. 
Amer.  Pract.  and  l^ews,  Feb.  16,  1889,  vii.,  No.  4,  p.  97. 

161.  Cosentino,  Giovanni:  Ricerche  ed  osservazioni  in  ostetricia. 
Annali  di  ostetricia  e  ginecologia,  Milano,  June,  1893,  xv.,  p.  449. 

162.  Crow,  Walter  A. :  The  Treatment  of  Abortion,  and  Some  of  the 
Complications  Incident  Thereto.  An.  of  Gyn,  and  Paediatry,  May,  1892, 
v.,  p.  473, 

163.  Crowell,  H,  C, :  Treatment  of  the  Uterine  Ca\nty  in  Abortions. 
Med,  News,  April,  1891,  No,  17,  p,  460, 

164.  De  Fresnay,  L,  Hamon:  Traitement  preventif  des  avortements  a 
repetition,     Soc,  de  med,  d'Anvers,  Annales  et  bulletin,  1890,  lii.,  p.  123. 

165.  DevUliers,  C. :  Avortement  provoque.  Nouveau  Diet,  de  med.  et 
Chir.  prat.,  1867,  iv.,  p.  329. 

166.  Doleris,  J,  A, :  Traitement  et  restauration  du  col  de  I'uterus  pen- 
dant la  grossesse,  Nouv,  Arch.  d'Obst.  et  de  Gyn.,  Paris,  1887,  ii.,  pp. 
427-445. 

167.  Fasola,  Emilio:  82  aborti  nel  triennio  1883-85.  Annali  di  oste- 
tricia, Milano,  1887,  p.  1. 

168.  Ferguson,  Frank  C. :  Curetting  the  TTterus  after  x\.bortion.  Indi- 
ana Med.  Jour.,  1890,  ix.,  p.  108. 

169.  Ferrand:  Contribution  a  I'etude  clinique  de  certaines  fausses 
couches.     Soc.  med.  de  I'Yonne,  1886,  xxvii.,  p.  46. 

170.  Fischer:  Meine  Erfahrungen  iiber  FrtihgeburtsfaUe.  Zeitschr.  f. 
"Wundarzte  u.  Geburtshelfer,  Hegnach,  1888,  xxxix.,  p.  332. 


216  REPORT   OF   THE   SOCIETY    OF   THE    LYIXGJX   HOSPITAL. 

171.  Foei*stei',  I'laiK-is:  Abortion  as  an  Etiological  Factor  in  Gynae- 
coloii-v    and    its    Treatment.       The    Post-Graduate,    May,    1891.    ix.,    i). 

17:^.  Gallard,  T. :  De  ravortement  an  i)i)int  dc  vue  uu'dieo-legal.  Paris, 
J.  13.  Baillicre  et  Fils,  1878. 

173.  Hart,  D.  Berry:  The  Anatomy  and  Mechanism  of  Early  Abor- 
tion.    Laboratory  Reports,  Eoy.  Col.  of  Physicians,  iii.,  p.  261. 

174.  I^a^vlev,  A.  C. :  A  Case  of  Abortion  Avith  Seqnehr.  Med.  and 
Surg.  Pep.,  18'.>0,  Ixii.,  p.  449. 

17.">.  llaynes,  Francis  L. :  Two  Cases  in  whit-li  the  Uterus  was  Per- 
forated by  a  Curette,  Both  Pecovering.  Amer.  Jour.  Obst.,  Xov.,  1890, 
xxiii,,  p.  1193. 

176.  Hegar,  Alfred:  Beitriige  zur  Pathologic  des  Eies  und  z.um  Abort 
in  den  ersten  Schwangerschaftsmonaten.  ^Monatschr.  f.  Geburtsk.  u. 
Frauenkr.,  Berlin,  1863,  xxi.,  p.  1. 

177.  Ileitzmann,  J.:  Der  protrahirte  Abortus  und  seine  Behandlung. 
Central))!,  f.  d.  gesammte  Therapie,  Wien,  1888,  vi.,  ]).  65. 

178.  Ilenrichsen,  K. :  Zur  Behandlung  der  Blutungen  nach  Abort. 
Central bl.  f.  Gyn.,  Leipzig,  1886,  x.,  p.  353. 

17'.'.  Herman,  G.  E. :  Decidua  vera  and  Reflexa  from  a  very  Early 
Abortion.     Trans.  Obst.  Soc.  of  London,  xxxii.,  1890,  p.  272. 

180.  Iloffnum,  Joseph:  Premature  Labor.  Trans.  Amer.  Assoc,  of 
Obst.  and  Gyn.,  1889,  ii.,  p.  358. 

181.  Johnson,  Joseph  Taber:  Abortion  and  its  Effects.  Maryland 
Med.  Jour.,  ^May  Ki,  1890,  xxiii. 

182.  Kelly,  J.  K. :  The  Treatment  of  Abortion,  Glasgow  Med.  Jour., 
Nov.,  1891,  p.  321. 

183.  Klein,  Gustav:  Entwickelung  und  Rtickbildung  der  Decidua. 
Zeitschr.  f.  Geb.  u.  Gyn.,  Stuttgart,  1891,  xxii.,  p.  247. 

184.  Klein wiichter,  Ludwig:  Die  kiinstliche  Unterbrechung  der 
Schwangerschaft,  Leipzig  u.  Wien,  2te  Aufl.,  1890,  Urban  und  Schwarz- 
enberg. 

185.  Lambert:  Traitement  preventif  et  curatif  de  la  fausse  couche  base 
sur  les  indications.     Soc.  de  med.  d'Anvers,  1888,  1.,  p.  11. 

ls(;.  Lecmans:  l"]tude  sur  le  traitement  de  Favortement.  Soc.  de  med. 
d'Anvers,  Ann.  et  buU.,  1888,  L.,  p.  81. 

187.  Legrand,  H. :  Avortement  gemellaire;  retention  du  placenta; 
deux  injections  intrauterines  avec  solution  de  Sublime  an  y,)^^;  hydrar- 
gyrisHie  aigii;  mort;  autopsie;  examen  histologique.  Bull,  de  la  Soc.  Anat- 
omicjue  de  Paris,  5e  serie,  1889,  iii.,  p.  321. 

iss.  Loiitr,  J.  AV. :  The  Curettage  after  Laboi- ;nid  Aboi-ticm.  N.  C. 
Med.  .lour.,  .hdy,  1890,  ]».  4(;i. 

ISi).  Lycett,  J.  ^y.■.  The  Pathology  and  Treatment  of  Abortion. 
Birmingham  Med.  Uev.,  1887,  xxii..  ]).  2o3. 

190.  Maygrier-Demelin :  l!ltu<le  cliniciiK^  siir  ravortement  multiphi  et 
en  ])arti(  ulier  snr  Tavortement  gemellaire.  Arch,  de  Toeol.  et  de  (ryn., 
Paris,  Feb.,  1892,  xix. 


THE    PKEMATUKE    INTERRUPTION    OF   PREGNANCY,  217 

191.  McKee,  E.  S. :  Ilcibitual  Abortion,  Amer,  Jour.  01)st.,  1892,  xxv., 
pp.  T75-780. 

192.  Merle,  Leon:  De  I'avortement  gemellaire,  Paris,  1892,  Oilier 
Ilenr}'-,  pj).  196,  8vo. 

193.  Miller,  Alex. :  Kotes  on  a  Case  of  Recurring  Miscarriage  from  an 
Unusual  Cause.     Glasgow  Med.  Jour.,  Dec,  1889,  p.  459. 

19-1:.  Napier,  A.  D.  Leith:  Statistical  Note  on  "Habitual"  Abortion. 
Satellite  of  Sajous'  Annual,  1889,  ii.,  p.  181. 

195.  Olivier,  Ad. :  Note  sur  un  cas  d'avortement.  Annales  de  la 
poliolinique  de  Paris,  1891,  i.,  p.  211. 

190.  Oui,  M, :  De  F intervention  dans  les  cas  d'avortement  lent.  Arch. 
Clin,  de  Bordeaux,  1892,  i.,  p.  435. 

197.  Polacco,  Roniolo:  Contributo  clinico  ed  istologico  alio  studio 
dell'aborto  interno.     II  Morgagni,  1887,  xxix.,  p.  783. 

198.  Priestly,  TV,  O, :  The  Lumleian  Lectures  on  the  Pathology  of 
Intrauterine  Death,     Brit,  Med,  Jour,,  1887,  i,,  pp,  660,  714, 

199.  Pogge,  H. :  Curette  eller  ikke  curette  ved  placentarrester  efter 
abort.  Tidsskr,  f,  d,  norske  Lgegefor.,  Christiania  and  Copenhagen,  1892, 
xii.,  pp,  68-72, 

200.  Eoss,  Geo,  T. :  Missed  Abortion,  Canada  Med.  Record,  Montreal, 
Dec,  1889,  xviii.,  p.  49. 

201.  Schuhl:  De  I'avortement  a  repetition  et  des  moyens  d'y  remedier. 
Ann.  de  Gyn.,  Paris,  May,  1891,  xxxv.,  p.  337. 

202.  Shauta:  Therapeutics  of  Abortion.  Med.  Chir.  Centralbl.,  Nov. 
26,  1893.     Also,  Arch.  Gyn.,  Obst.,  and  Pediatrics,  1893,  p.  452. 

203.  Shollenberger,  Chas.  P.:  Spontaneous  Abortion.  Denver  Med, 
Times,  1889-90,  ix,,  p.  332, 

204.  South  wick,  G,  R, :  The  Treatment  of  Abortion  at  the  Fourth  or 
Fifth  Month,  with  Retained  Placenta,  Amer.  Jour.  Obst.,  1885,  xviii., 
p.  932. 

205.  Stratz,  C.  H. :  Over  graviditas  extrauterina.  Nederl.  Tijdschr. 
V.  verlosk.  en  gynaec,  Haarlem,  1890,  ii.,  pp.  124-139. 

206.  Stumpf,  Max:  Zur  ^tiologie  und  Behandlung  der  Fehl-  und  Fruh- 
geburt,     Miinch,  med,  Wochenschr,,  Nov,,  1892,  xxxix,,  p.  780, 

207.  Ter-Grigoriantz :  Beitrage  zur  Abortbehandlung,  Centralbl,  f. 
Gyn.,  Leipzig,  1891,  xv.,  p,  865, 

208.  Thomas,  T,  Gaillard:  Abortion  and  its  Treatment,  from  the 
Standpoint  of  Practical  Experience,  A  special  course  of  lectures  delivered 
at  the  Coll,  of  Phys,  and  Surg,,  New  York,  session  of  1889-90. 

209.  Tintelin,  Felix-Prosper:  De  I'avortement  des  5e  et  6e  mois  de  la 
grossesse  considere  surtout  au  point  de  vue  de  la  delivrance,  Nancy, 
1888,  80  pp,,  4to,  No.  278. 

210.  Yeit,  J,:  Miiller's  Handbuch  der  GeburtshtiLfe,  bd.  ii,,  1888, 
Stuttgart,  pp,  1-220. 

211.  Vibert,  Louis:  Contribution  a  I'etude  du  traitement  de  la  re- 
tention du  placenta  dans  I'avortement.  Paris,  1891,  52  pp.  4to,  G. 
Steinheil. 


5il8  REPORT   OF   THE    SOCIETV   OF   THE    LYIXG-IX    HOSPITAL. 

212.  AYanl,  Sttinlev  M. :  Abortion — its  Proper  aiul  Improper  Manage- 
ment.    Amer.  Gynecol.  Jour.,  1802,  ii.,  p.  5(30. 

213.  AVarner,  Helen  F. :  The  ]\ranagement  of  Abortion.  The  Med. 
Age,  1885,  iii.,  p.  433. 

214.  Watson,  -T.  A.:  Treatment  of  Abortion.  X.  C.  Med.  Jonr., 
May,  1892,  p.  250. 

215.  AVing,  Elbert:  Re]>ort  of  a  Case  of  Abortion  in  tlie  Third  Month 
of  Gestation,  Avith  detention  of  the  Placenta  for  Five  Months  without 
Sepsis.     Chicago  Med.  Jour,  and  Exam.,  1888,  Ivi.,  p.  334. 

216.  AVinckel,  F. :  Ueber  den  A^'erlauf  und  die  Behandlung  des  Abortus 
und  Partus  immaturus.     "Miinch.  med.  AVochenschr. ,  1888,  xxxv.,  p.  463. 


OBSTETKICAL  ASEPSIS  AND  THE  KESULTS  OF  SIX  YEARS' 
OUTDOOE  SERVICE.  —  MORBIDITY  AND  MORTALITY 
STATISTICS   OF  10,233   CASES. 

By  Samuel  W.  Lambert,  M.D. 

Obsteteical  Asepsis  in  the  Outdook  Service, 

The  foUoTving  pages  will  describe  the  methods  of  applying  the  princi- 
ples of  surgical  cleanliness  to  the  needs  of  the  outdoor  service  of  this 
Hospital.  The  details  are  a  result  of  the  combined  efforts  of  the  members 
of  the  Medical  Board,  and  no  personal  claim  is  made  of  priority  or  author- 
ship. The  routine  work  of  the  Hospital  is  done  in  the  same  manner  every 
week  of  the  year,  without  regard  to  the  personal  views  of  the  attending 
physician  who  may  be  on  duty.  Of  course  this  routine  has  been  a  thing 
of  growth,  and  changes  hav^e  at  times  been  frequent,  and  often  of  a  radical 
nature.  But  no  change  has  been  made  without  a  previous  discussion  by 
the  Medical  Board  and  without  the  approval  of  a  majority  of  the  five 
attending  physicians. 

The  outdoor  service  of  the  Lying-in  Hospital  has  been  described  in 
previous  Reports  often  enough  to  need  no  repetition  at  this  time.  It  is  a 
tenement-house  service  in  the  most  densely  populated  district  in  the  world. 
The  application  of  the  principles  of  surgical  asepsis  in  such  a  service  is  a 
complex  problem,  which  may  be  considered  under  three  chief  subdivisions: 
I.  Asepsis  of  apparatus. 
II.  Asepsis  of  operator. 

HI.  Asepsis  of  patient. 

Asepsis  of  Obstetrical  Instruments  and  Apparatus. 

The  Labor  Bag. — This  Hospital  depends  upon  its  tenement-house 
patients  to  furnish  at  the  time  of  their  lying-in  only  a  large  pail  for  waste 
douche,  a  basin  for  hand  washing,  and  a  plentiful  supply  of  hot  water. 
All  other  apparatus  which  may  be  needed  is  taken  to  the  case  from  the 
Hospital.  The  outdoor  service  employs  twenty-four  labor  bags,  one  of 
which  goes  to  every  case.      Each  bag  contains  all  the  utensils  needed  for 


220 


REPORT   OF   THE   SOCIETY    OF   THE    LYIXC-IN    HOSPITAL. 


the  delivery  of  a  normal  case  of  labor. 
ins:  list  of  articles: 

Kubber  tj-oods : 

Lying-in  Hospital  pad  i^Keily). 
Douche  bag. 

Agate  ware: 

Nest  of  three  basins. 

In  glass  bottles: 

Soft  rubber  catheter. 
Tape  for  cord. 
Linen  for  cord. 
Linen  for  eye  wipes. 

Drugs : 

Acetic  acid. 

Alcohol. 

Ergot. 

Starch. 

Solution  of  silver  nitrate,  Ifo. 

Compound  cathartic  pills. 

Bichloride  of  mercury  tablets. 


Its  contents  includes  the  follow- 
In  glass  boxes: 

\'ascline. 

Soap. 
In  copper  or  brass  cans: 

Douche  tubes. 

Yulva  pads. 

Cotton  wipes. 

Nail  brush. 

Other  articles: 

Pelvimeter. 

Eye  dropper. 

Scales. 

Scissors. 

Tape  measure. 
Blanks: 

Miniature  labor  and  child  charts. 

Ile})ort  blanks. 

Ijirtli  certificate. 

Small  blank  pad. 


These  bags  are  made  of  leather  and  lined  with  leather.  They  are  lY  x 
0x9  inches  in  size;  they  open  wide  at  the  top,  and  one  when  filled  weighs 
20  pounds.     One  of  them  is  represented  in  the  accompanying  cut  (Fig.  1). 

A  room  is  sjiecially  devoted  to  the  use  of  the  outdoor  department  as  a 
laboratory  and  is  fitted  U])  Avith  the  necessary  glass  tables,  supply  shelves, 
sinks,  and  sterilizers.  The  preparation  of  the  dressings,  the  sterilization  of 
the  instruments,  and  the  cleaning  and  refilling  of  the  bags  needed  in  the 
service  are  done  in  this  room.  A  general  view  of  the  room  is  given  in  the 
accomjmnying  ])late  (Fig.  2),  and  the  special  arrangement  of  the  apparatus 
is  shown  in  the  plan  on  page  221  (Fig.  3). 

The  waslitub  (3)  is  of  porcelain,  and  the  dripboard  (2)  of  glass.  The 
tables  are  of  sim))le  consti'uction  and  have  glass  t()j)s.  The  table  nuirked 
11  in  the  |»l;iM  li;is  ;i  cciili';!!  sliclf  (  \-J\  on  wiiich  the  stock  bottles  for  solu- 
tions and  a  rcsei've  siip])ly  of  drug  bottles  are  kept,  for  renewing  brok(Mi 
articles  when  tlie  bags  are  refilled.  The  sluOves  (17)  over  table  (1<»)  are 
foi-  the  st<jrage  of  the  co))p('r  cans  of  wipes,  pads,  douche  tubes,  and  nail 
l)rushes.      The  remaining  relerences  to  the  ])lan  <'xplain  themselves. 

Tlie  Brainhall-I)e;ine  stei-ilizers  ai'e  arranged  to  expose  their  contents  to 
the  action  of  steam  under  a  pressure  of  ten  pounds.  The  a])])aratus  is  a 
eylin<ler  ojx'n  at  one  end,  and  the  steam  is  genei-ated  from  watei'  in  the 
bottom,  lieated  by  a  liunsen  flame  nmh-i-neatli.  The  ai'ticles  to  be  steril- 
ized are  placed  u|)on  a  rack  ovei-  the  boiling  wafiM-.  Thei'e  is  a,  steam- 
gauge  and  safety-valve,  which  latter  is  set  at  hn  pounds  pi-essure  (Fig.  4). 

The  work  is  done  b}'  the  nurses,  two  of  wlioni  ai-c  on  duty  during  the 


Fig.  1. — Labor  Bag. 


Fig.  4. — Steam  Stehilizer. 


ASEPSIS,    MORBIDITY,    AND    MORTALITY, 


231 


day.  They  leave  the  whole  number  of  bags  in  condition  for  immediate 
use  when  going  off  duty  each  night,  and  it  is  a  very  unusual  thing  for  the 
supply  of  clean  bags  to  be  exhausted  by  morning.  The  refilling  of  one  of 
these  labor  bags  involves  a  considerable  amount  of  sterilization  and  clean- 
ing, but  a  supply  of  articles  already  prepared  is  kept  on  hand,  and  the 
process  is  therefore  much  facilitated.  When  a  bag  is  returned  from  a  case, 
it  is  emptied  of  its  contents,  and  is  then  wiped  out  with  a  cloth  dampened 


Fig.  3.     Plan  of  Nueses'  Labokatoky. 


1, 1.  Bramhall-Deane  Sterilizers. 

2.  Glass  table. 

3.  Porcelain  washtub. 

4.  Glass  table. 

5.  Towel  Rack. 

6.  Range. 


7.  Boiler. 

8.  Soiled  linen  hamper. 

9.  Instrument  case. 

10.  Glass  table. 

11.  Glass  table. 

12.  Central  shelf. 


13.  Glass  table. 

14.  Stock  closet. 

15.  Shelves  for  bags. 

16.  Vestibule,  separated  by  iron  rail. 

17.  Shelves  for  copper  cans. 


with  bichloride  of  mercur}^  solution.  It  is  filled  immediateh^  with  a  fresh 
supply,  and  is  frequently  used  twice  in  twenty-four  hours.  Each  of  the 
varied  list  of  articles  contained  in  these  bags  demands  a  different  treat- 
ment in  order  to  render  it  surgically  clean.  The  object  of  the  system  of 
preparation  detailed  below  is  to  furnish  for  each  confinement  the  necessary 
supply  of  aseptic  dressings  and  apparatus. 

The  Lying-in  Hospital  bed  pad  is  modified  from  the  model  of   Dr. 
Kelly  in  such  a  way  that  the  seams  are  less  numerous  and  the  pad  more 


222  REPORT   OF   THE   SOCIETY    OF   THE    LYING-IN    HOSPITAL. 

dill-able  (Fig.  •r>V  One  of  these  pads  is  used  at  every  confinement  to  protect 
the  bed  from  the  bk)oil  and  liquor  amnii,  and,  what  is  eipially  important,  to 
protect  the  patient  fi'om  the  infective  bedding  Avhich  is  a  constant  accom- 
]ianiinent  of  the  t)utdoor  service.  The  j)ad  is  also  used  instead  of  a  douche 
pan  to  receive  the  postpartum  vaginal  douche  and  convey  the  overflow  to  a 
pail  on  the  floor.  These  pads  are  cleaned  by  washing  with  soap,  water, 
and  brush,  and  sterilized  by  scrubbing  with  carbolic  sohition  (5  per  cent.). 
Kubber  does  not  stand  the  action  of  corrosive  sublimate  nor  of  heat  either 
dry  or  moist.     The  life  of  a  pad  under  this  routine  is  twelve  months. 

The  douche  bag  used  is  the  ordinary  four-quart  fountain  syringe,  which 
is  also  made  of  rubber,  and  is  cleaned  and  sterilized  in  the  same  manner  as 
the  rubber  pad  (Fig.  5).  These  bags  are  used  exclusively  for  the  giving  of 
bichloride  of  mercury  douches  in  normal  labor  cases.  A  bag  under  this 
care  will  last  six  months. 

The  three  agate  basins  in  the  bag  form  a  nest,  for  easy  packing  (Fig.  0). 
The  larger  two  contain  a  })int,  and  the  bichloride  tablets  are  of  such  a 
strength  that  one  in  a  })int  makes  a  solution  1  to  2,000;  these  basins  are 
used  to  hold  the  bichloride  solution.  One  will  be  used  for  disinfecting 
the  hands,  and  the  other  to  contain  the  necessary  amount  of  concentrated 
solution  of  corrosive  su1>limate  to  be  added  to  the  douche.  The  shallower 
basin  is  used  to  hold  the  scissors  and  tape  for  the  cord  and  some  of  the  eye 
wipes.  These  articles  are  placed  upon  the  basin  just  before  the  end  of  the 
second  stage,  where  the}''  will  be  convenient  when  needed.  These  basins 
are  sterilized  by  washing  with  sapolio  and  corrosive  sublimate  solution  1  to 
1,000. 

The  douche  tubes  which  are  used  for  normal  cases  are  straight  vaginal 
tubes  of  glass  (Fig.  13).  A  routine  postpartum  vaginal  douche  is  given,  and 
these  tubes  are  used  to  diminish  the  chance  of  the  douche  being  delivered 
into  the  uterus.  The  tubes  have  in  the  past  been  carried  in  glass  cylinders 
Avhich  are  shaped  like  large  test  tubes.  Their  blind  end  is  perforated,  and 
when  in  use  both  ends  are  plugged  with  absorbent  cotton.  These  cylinders 
and  their  contents  are  sterilized  in  the  pressure  steam  drums.  It  has  been 
voted  l)y  the  Medical  Board  to  change  these  glass  cylinders  for  those  of 
brass,  similar  to  the  copper  cylinders  descril)ed  below  as  b(>ing  used  for  the 
dressings  and  n;iil  brushes.  Such  a  cylinder  is  shown  in  Fig.  !>  l)elow. 
The  original  c(jst  (^f  the  brass  is  somewhat  more  than  that  of  the  glass, 
but  the  loss  by  breakage  is  practicall}'  nothing.  Experience  has  shown 
also  that  the  brass  is  better  than  the  copper,  because  solid  brass  tubing  can 
be  ))urchased,  while  the  co|>pei'  must  have  a  longitudinal  seain  along  the 
side.  The  brass  will  therefore  outlast  the  copper.  The  lirst  cans  were  of 
nickel-plated  zinc,  but  they  did  not  stand  the  frequent  exposure  to  steam, 
as  the  plating  wore  olf  and  the  zinc  became  oxidized. 

Tiie  soft  rubber  catheter  is  the  onlv  foriu  used  in  the  oiiLdooi'  service. 
It  is  sterilized  by  boiling  in  water,  ami  is  kept  in  :i  coi-kcd  bottle  immersed 
in  saturated  boracic  acid  solution.  The  tjipc  nscd  for  tying  the  umbilical 
cord  is  bol;liin,  one-(juarter  inch  wide.  This  is  cut  in  lengths  of  twelve 
inches,  and  six  such  pieces  arc  placed  in  a  screw-to})  b(jttle.     Small  pieces 


^mmFmri^^i,~-s^si^ssB^^i^^^^^ism^?^^miT^i 


Fig.  5.— Bed  Pad  and  Douche  Bag. 


Fig.  6. — Agate-waee  Basins. 


Fig.  7. — Bottles  for  Catheter,  Tape,  Dry  and  Wet  Gauze. 


Fig.  8. — Drugs  Contained  in  Labor  Bag. 


Fig    9.— Copper  Cans  for  Cotton,  Vulva  Pads,  and 
Nail  Brush.     Brass  Cylinder  for  Douche  Tubes. 


ASEPSIS,    MORBIDITY,    AND    MORTALITY.  223 

of  gauze  two  inches  square  are  used  to  surround  and  protect  the  stump  of 
the  cord.  These  pieces  of  gauze  are  placed  in  a  dry,  four-ounce,  salt- 
mouth  glass  bottle.  These  bottles  containing  tape  and  gauze  are  sterilized 
in  the  Bramhall-Deane  sterilizer.  Small  squares  of  gauze  similar  to  those 
used  on  the  cord  are  kept  immersed  in  an  excess  of  saturated  solution  of 
boracic  acid  in  a  foiu'-ounce,  salt-mouth  bottle.  They  are  also  sterilized, 
and  are  used  to  wipe  out  the  baby's  mouth  and  eyes  immediately  after 
birth  (Fig.  7). 

The  list  of  drugs  kept  in  the  bags  is  a  short  one.  The  bottles  are  four- 
ounce  tincture  bottles.  Ergot  and  dilute  acetic  acid  are  for  use  in  case  of 
hgemorrhage.  Solution  of  nitrate  of  silver  of  one  per  cent,  strength  is  to 
drop  in  the  baby's  eyes  after  birth,  and  tablets  of  bichloride  of  mercury, 
compound  cathartic  pills,  starch,  and  alcohol  complete  the  list.  Soap  and 
vaseline  are  carried  in  one-ounce  ointment  jars.  The  vaseline  is  used  only 
to  anoint  the  new-born  baby,  and  never  to  lubricate  the  examining  finger  or 
hand.  The  ordinary  yellow  vaseline  and  commercial  green  soap  are  bought 
in  25-pound  jars,  and  are  transferred  to  the  small  service  jars,  which  are 
then  sterilized  in  the  steam  sterilizers  (Fig.  8). 

Absorbent  cotton  is  bought  in  rolls  of  one  pound.  Two  grades  are  pur- 
chased; the  better  is  used  for  the  surgical  dressing  of  wounds  and  for  the 
application  of  pressure  to  engorged  breasts.  The  cheaper  grade  is  used  to 
make  the  absorbent  vulva  pads  and  to  sponge  and  cleanse  the  genitals  of 
the  parturient  and  postpartum  patients.  This  cheaper  form  of  cotton  is 
known  in  the  trade  as  "  cotton  waste;  "  it  is  equally  absorbent  and  clean, 
but  does  not  lie  in  the  lap  so  smoothly  as  does  the  better  grade.  It  also 
contains  small,  hard  masses  of  matted  cotton.  The  roll  of  waste  is  cut 
into  sections  four  inches  long,  and  is  then  unrolled  and  divided  into  pieces 
about  four  inches  square  and  half  an  inch  thick.  Two  of  these  squares 
rolled  in  a  piece  of  absorbent  gauze  to  make  a  flat  package  1x2x8 
inches  form  the  vulva  pad  of  the  outdoor  service. 

These  pads  are  packed  in  cylindrical  copper  cans  three  inches  in  diam- 
eter and  six  inches  long.  The  ends  of  the  cans  are  closed  by  perforated 
covers,  which  are  attached  by  brass  chains  to  the  cylinder.  The  holes  in 
the  covers  of  the  copper  cans  are  protected,  from  the  entrance  of  dust  and 
germs  by  a  layer  of  absorbent  cotton,  and  the  pads  are  placed  within  these 
caps.  These  cans  are  then  sterilized  in  the  steam -pressure  sterilizers.  A 
number  of  the  pieces  of  cotton  waste  are  packed  in  a  similar  but  slightly 
larger  copper  can  (8x3  inches)  and  sterilized  in  the  same  manner ;  they  are 
used  as  "  sponges  "  at  the  confinements  (Fig.  9). 

The  nail  brushes  which  are  used  are  inexpensive ;  the  back  is  of  wood 
and  the  "  bristles  "  are  wooden  fibres.  They  are  placed  in  copper  boxes 
like  those  just  described,  but  smaller  (3  x  1  x  |  inch),  in  which  they  are 
sterilized  in  the  same  manner.  While  in  use  the  nail  brush  is  kept  in  one 
of  the  basins  of  bichloride  solution.  The  life  of  a  nail  brush  under  this 
treatment  is  about  eiffht  weeks.  The  scissors  are  sterilized  at  the  time  of 
using  by  being  immersed  in  corrosive  sublimate  solution  1  to  2,000.  The 
life  of  a  pair  of  scissors  is  longer  than  one  might  expect — about  one  year 


•^>-^>4  REPORT   OF   THE   SOCIETY    OF   THE    LYIXG-IN    HOSPITAL. 

— under  such  treatment.  The  })elvinieter  and  scak^s  are  kept  clean,  but 
receive  no  special  disinfection. 

The  Lahor  Bti1.—\\\  normal  cases  of  labor  are  delivered  on  their  o^vn 
beils.  The  motlitieil  Kelly  })ad  of  rubber  is  used  to  protect  the  bed  from 
the  blood  ami  discharges  incident  to  the  labor,  and  to  protect  the  patient 
and  the  accoucheur's  hamls  from  the  bod  and  bedding.  In  order  to  render 
the  beds  less  infective,  freshly  Uiundered  linen  is  s})read  whenever  the  patient 
possesses  such  a  luxury.  Sometimes  it  is  j^ossible  to  use  an  enamelled  cloth 
untler  the  bed  sheet  as  a  greater  j-yrotection  to  the  mattress;  but  it  is  often 
necessary  to  dehver  the  patient  upon  the  dirtiest  of  bedding  and  in  the 
most  unsteady  of  double  bedsteads.  The  side  position  is  invariably 
insisted  upon  at  the  time  of  delivery,  because  it  raises  the  jjatient's  genitals 
from  the  bed  and  renders  less  likely  uncleanliness  both  of  the  patient  and 
of  the  attendant.  This  side  position  allows  a  better  observation  of  the 
perineum  during  the  birth,  and  permits  the  necessary  exposure  of  the  bnt- 
tockf  At  the  same  time  more  of  the  patient's  shoulders  and  legs  are  cov- 
ered than  is  ])ossible  in  the  dorsal  posture. 

Instrument  Table. — It  is  usually  impossible  to  find  an  aseptic  surface  to 
serve  as  an  instrument  table  in  the  homes  of  our  patients.  The  bedrooms 
are  often  so  small  tliat  the  Ijed  takes  \\\\  three-fourths  of  the  floor  space. 
It  is  our  custom,  therefore,  to  use  the  aseptic  materials  brought  from  the 
Ilos])ital  directly  from  the  original  packages,  and  never  to  spread  them  out 
on  a  table,  which,  although  more  convenient,  would  nullify  the  previous 
care  given  to  their  aseptic  preparation.  The  douche  bag  is  hung  on  some 
convenient  hook,  and  the  end  of  the  douche  tube  is  kept  in  the  bag  itself. 
immersed  in  the  solution.  The  tape  and  scissors  are  laid  upon  the  shallow 
basin,  and  the  nail  brush,  when  not  in  its  proper  case,  is  kept  in  the  basin 
of  antiseptic  solution  Avhich  is  used  for  the  hands.  The  linen  for  the  eyes 
and  that  for  the  ccjrd,  the  soap  and  vaseline,  the  cotton  wipes  and  vulva 
pads,  are  used  directly  from  their  respective  glass  and  copper  receptacles. 
These  basins  and  cans  and  ]:)ottles  are  ])lace(l  on  some  table,  or  frecpiently  a 
wooden  chair  is  taken  for  an  "  instrument  table." 

The  application  of  the  principles  of  asepsis  to  the  para})h('niali;i  nec- 
essary to  handle  operative  cases,  denumds  an  extension  of  the  methods  just 
described.  In  all  operative  cases  a  larger  number  of  persons  must  render 
their  hands  aseptic,  and  a  greater  amount  of  obstetric  dressings  must  be 
u.sed  than  at  normal  cases.  The  contents  of  the  labor  bag  which  is  detailed 
U)  an  ojierative  case  must  be  reinforced  by  additional  cans  of  cotton  wi])es, 
by  extra  nail  bruslies  and  soa|)  jars.  It  is  oui'  custom,  also,  to  isolate  the 
field  of  operation  IVdin  sun-omidiiig  sources  of  possiblr  inlcctioii  hy  \\r;i|)- 
ping  the  legs  and  covering  th(;  abdomen  niid  the  K'elly  |i;i<l  <>ii  which  the 
patii.'Ut  lies  witli  stei'ilized  towels. 

These  towels  are  2<»  by  l-'t  inches  in  size.  Tiiey  m-e  made  of  smooth 
huckaliack,  and  finished  by  a  sim|)le  hem  at  each  end.  I'aclcages  of  six, 
wraj)ped  and  .securely  ]»inned  in  a  seventh  towel,  an;  stei-ilized  in  the  steam- 
pressure  apparatus  (Fig.  lo).  Patients  are  removed  IVom  theii-  low  beds 
after  Ijeing  anaesthetized  and  are  brought  into  the  lai-gest  and  lightest  room 


1 

.       1 

m 

^.M«;2^^~.....fl#*!2j| 

"^-  '  ■  .T^^iBiWSKi^SftiS:^ 

Fig.    10. — Bundle    of    Stekilizkd 
Towels. 


Fig.  11. — Pehineorrhaphy  Set 
IN  Glass  Cylinder. 


Fig.  13. — Sutdre  Material. 


Fig.  13. — Vaginal  and  Intr.\uterine  Douche  Tubes.    Glass 
Cylinders  for  Gattz.e  or  Tubes 


ASEPSIS,    MORBIDITY,    AND    MORTALITY.  225 

their  tenement  affords;  they  are  placed  upon  a  talile,  and  after  the  opera- 
tion, again  phiced  in  their  bed.  These  operating'  tables  are  improvised  by 
covering  a  kitchen  table  with  some  old  woollen  comforter  or  blanket  and 
placing  the  rubber  Kelly  pad  on  the  end.  Most  operative  deliveries  are 
done  Avhile  the  patient  is  in  the  dorsal  position.  An  instrument  table  is 
furnished  by  covering  a  small  table  with  one  of  the  sterilized  towels. 

The  different  operations  require  a  longer  or  shorter  list  of  instruments, 
which  are  sent  from  the  Hospital  in  a  sterile  condition,  in  order  to  avoid 
the  transportation  of  an  instrument  sterilizer,  and  to  economize  the  expen- 
diture of  time.  Sets  of  the  necessary  instruments  for  the  minor  operations 
of  curettement  and  perineorrhaphy  are  kept  in  readiness  for  immediate  use. 
Special  preparation  is  necessary  to  prepare  for  a  forceps  operation  or  any 
more  elaborate  procedure. 

The  instruments  and  additional  dressings  are  taken  from  the  Hospital 
to  the  case  in  special  operation  bags,  which  are  like  the  labor  bags,  but 
somewhat  smaller. 

A  perineorrhaphy  set  consists  of: 


Three  curved  needles. 
Thumb  forceps. 
Two  clamps. 


Needle  holder. 
Scissors. 
Suture  material. 


The  instruments  are  taken  apart  and  wrapped  in  absorbent  cotton,  to  pre- 
vent rusting;  they  are  then  packed  in  a  glass  cylinder,  which  is  plugged  with 
cotton,  and  the  whole  sterilized  in  the  steam-pressure  apparatus  (Fig.  11). 
The  suture  material  is  either  catgut  for  lesser  operations,  or  silkworm  gut 
for  those  of  greater  degree.  The  silkworm  gut  is  sterilized  by  the  Hospital 
by  putting  the  strands  in  test  tubes  plugged  with  cotton  and  exposing  it  to 
steam  under  pressure  for  twenty  minutes.  These  tubes  are  re-sterilized  in 
the  steam  sterilizer  each  time  they  are  opened  for  the  removal  of  a  portion 
of  their  contents.  The  catgut  is  prepared  by  a  process  of  boiling  in  abso- 
lute alcohol  after  it  has  been  soaked  and  washed  in  ether.  Each  strand  is 
sealed  in  a  separate  glass  tube  immersed  in  absolute  alcohol.  The  tube 
is  broken,  and,  in  order  to  soften  it  and  render  it  more  flexible,  the  catgut 
is  wet  in  an  aqueous  solution  of  some  antiseptic  before  using.  Silk  can  be 
prepared  in  the  same  manner  (Fig.  12). 

All  instruments  are  sterilized  in  the  steam  drums,  except  in  the  unusual 
oases,  when  a  portable  boiler  is  carried  to  the  patient's  home.  The  instru- 
ments are  first  wrapped  in  a  towel  and  securely  pinned;  they  are  then 
exposed  to  the  steam,  and  the  bundle  is  not  opened  until  they  are  needed. 
Such  bundles,  containing  the  obstetric  forceps  or  the  necessary  outfit  for 
curetting,  are  kept  ready  for  use,  at  short  notice,  in  the  instrument  case 
in  the  outdoor  department  laboratory.  The  curettement  set  consists  of 
curettes,  volsellum,  vaginal  speculum,  cervical  dilator,  and  intrauterine 
douche  tube. 

The  woven  silk  bougie  which  is  used  for  the  induction  of  labor,  and  the 
catheter  of  the  same  jnaterial,  with  its  metal  stylet,  used  for  replacing  a 
prolapsed  cord,  are  sterilized  by  scrubbing  with  soap,  water,  and  nail  brush, 
15 


226  REPORT   OF  THE   SOCIETY   OF   THE   LYIXG-IX   HOSPITAL. 

foUoweil  bv  similar  treatment  with  carbolic  solution.  These  instruments 
are  taken  to  the  place  of  oi)eration.  wrapped  in  sterile  gauze. 

The  more  serious  operations,  such  as  cranit>t()niy,  symphysiotomy,  and 
Cesarean  section  have  been  performed  successfully  in  this  service.  The 
ase]nic  ])rei)aration  of  apparatus  recpiires  a  careful  extension  of  these  same 
principles.  Soft  rubber  trays  for  instruments,  and  larger  su})i)lies  of  towels, 
jars  of  sterile  water,  and  sui)])lies  of  instruments  from  the  indoor  service 
are  transported  to  the  patient's  home.  Portable  instrument  sterilizers  are 
often  usetl  on  such  occasions.  Since  the  opening  of  the  indoor  service, 
patients  requiring  such  severe  operations  are  usuall}'^  brought  to  the  Hospi- 
tal and  oi>erated  upon  there. 

The  lesser  o])erations  of  catheterization,  packing  the  vagina  or  the  uterus 
with  gauze,  anil  the  giving  of  enemata  are  of  such  frequent  occurrence  that 
the  resident  staif  must  be  constantly  ready  to  carry  them  out.  The  mem- 
ber of  the  house  statf  who  is  acting  as  instructor  to  the  students  on  labor 
dutv  carries  with  him  on  his  visits  a  bag  which  contains  a  nail  brush,  soap, 
and  bichloride  tablets  for  his  hand  washing,  also  a  catheter,  an  enema 
syringe,  and  the  instruments  for  packing  the  uterus. 

The  passiuii'  of  a  catheter  is  alwavs  done  bv  sight,  and  never  bv  touch 
alone.  The  labia  majora  are  separated  by  one  sterile  hand,  Avhile  the  other 
first  bathes  the  exposed  vestibule  with  bichloride  solution  and  then  inserts 
tiie  soft  rubljcr  catheter  into  the  meatus  and  l)ladder.  If  a  s})ecimen  of 
urine  is  wanted,  it  is  caught  and  saved  in  the  bottle  which  originally  held 
the  catheter.  Of  course  this  bottle  must  be  rinsed  free  of  the  boracic  acid 
solution  before  being  used  for  the  urine. 

The  instruments  for  packing  the  uterus  are: 

A  uterine  dressing  forceps. 

A  volsellum. 

A  speculum. 

A  (juantity  of  gauze  in  a  glass  cylinder. 

The  necessary  instruments  are  wrapped  in  a  towel  and  are  then  ster- 
ilized by  the  steam  a])paratus.  The  iodoform  gauze  is  packed  in  one  of  the 
glass  cylinders  formerly  used  for  the  douche  nozzles,  and  this  is  also  exposed 
Ui  the  heat  of  steam  under  ])ressure.  These  cylinders  are  11  by  1^  inches 
in  size,  and  contain  a  strip  of  gauze  tAvelve  yards  long  and  two  inches  wide. 

The  method  <.f  packing  the  vagina  or  uterus  is  to  place  the  patient  upon 
her  back  and  across  the  bed;  to  insert  a  vaginal  retractor;  to  grasp  the 
anterior  lip  of  the  cervix  with  tlie  volsellum  and  draw  the  uterus  down  until 
the  OS  externum  is  in  full  view ;  then  to  introduce  the  gauze  directly  from  its 
rjriginal  glass  i'('c<'])tacle  intf)  the  uterus  (Fig.  i;>).  One  hand  of  tlie  opera- 
tor holds  tin'  dressing  forceps,  and  the  other  the  volsellum.  An  assistant 
holds  the  retractor  in  one  hand  and  the  gauze  receptacle  in  the  other. 
Tiie  r)j)eration  can  be  done  aseptically  witliout  an  assistant  by  em])loving  a 
self-retaining  speculum.  The  glass  cylindei-  is  hehl  l)etwecn  the  knees,  or 
in  the  hand  which  holds  the  volsellum.  If  the  uterus  is  to  be  packed,  the 
first  portion  of  tin*  gauze  is  carried  well  up  to  th(?  fundus,  and  the  uterine 
cavity  is  filled  gradually  downward  from  the  fundus.     "When  the  uterus  is 


ASEPSIS,    MORBIDITY,    AXD    MORTALITY.  227 

fully  packed,  the  vagina  may  be  treated  in  like  manner.  The  gauze  is 
carried  by  the  dressing  forceps  into  the  fornices  of  the  vagina  and  packed 
around  the  cervix,  then  over  the  cervix;  and,  finally,  the  vagina  is  tilled 
while  the  speculum  is  withdrawn  slowly. 

Bacteriological  examinations  of  the  various  articles  prepared  in  the 
manner  descriljed  have  been  frequently  made.  The  results  of  these  tests 
have  shown  that  the  methods  in  use  were  efficient. 

A  recent  report  is  given  in  detail : 

Dressings  from   Obstetrical  Bag,  Xo.  18. 

Bag  had  l^een  on  the  shelf  five  days  before  examination. 

Bacteriological  examination : 

Glass  catheter,  sterile. 

Yaginal  douche  tube,  sterile. 

Nail  brush,  sterile. 

Yulva  pad,  sterile. 

Cotton,  sterile. 

Dry  cord  dressings,  a  gas  producing  bacillus  in  every  way  resembling 
bacillus  coli  communis. 

Cord  tape,  sterile. 

Starch,  bacillus  coli  communis. 

Silver  nitrate  solution  (1  per  cent.),  sterile. 

Eye  wipes  in  boracic  acid  (saturated  solution),  sterile. 

A  subsequent  examination  of  another  sample  of  dry  cord  dressings 
showed  these  to  be  sterile. 

An  older  report  on  one  of  the  obstetric  bags  showed  all  articles  sterilized 
by  steam  under  pressure  to  be  sterile.  But  articles  not  so  treated,  the 
rubber  pad,  cord  taj^e,  and  cord  dressings,  which  had  been  treated  with 
milder  measm^es,  contained  various  species  of  staphylococci  and  bacilli.  It 
was  as  a  result  of  such  reports  from  the  bacteriologist  that  the  sterilization 
by  steam  was  extended  to  the  treatment  of  nearly  all  the  contents  of  the 
labor  bag. 

Asepsis  of  Accoucheur. 

A  prophylactic  abstinence  from  contact  ^vith  infectious  matter  of  all 
kinds,  and  especially  with  infectious  patients,  is  demanded  of  the  medical 
attendants  who  give  the  routine  care  to  the  patients  of  this  Hospital.  The 
student,  it  is  true,  comes  to  the  work  from  we  know  not  what ;  but  during 
his  first  twenty-four  hours  he  is  watched  and  directed  during  all  his 
attempts  to  disinfect  himself,  and  after  that  period  he  is  under  careful 
oversight,  as  outlined  in  another  article  in  this  report.  From  the  time  he 
comes  on  duty  until  his  two  weeks'  service  is  finished,  he  cannot  become 
infected  from  any  work  of  the  Hospital,  and  he  is  not  allowed  to  undertake 
any  other  work  of  a  medical  nature. 

In  order  to  care  for  both  normal  and  infected  cases,  the  service  is  divided 
into  a  regular  ser^ace  and  a  septic  ser^^ce.  If  symptoms  of  a  suspicious 
nature  occur  in  any  patient,  she  is  isolated  from  the  care  of  the  student, 


228  REPORT   OF   THE   SOCIKTV    OF   TPIE    LYING-TX   HOSPITAL. 

and  is  attended  bv  the  sej)tie  de})ai'tnient,  as  described  below.  The  resi- 
dent statf  of  physicians  <.lo  not  come  in  contact  Avith  infectious  cases, 
except  in  the  earlier  stages  of  suspected  infection.  As  soon  as  a  case 
develops  fever  and  signs  of  infection,  it  is  given  into  the  hands  of  one  par- 
ticular member  of  the  resident  stalf,  ^vho  is  detailed  for  septic  work.  lie 
makes  the  rontine  ])ostpartum  calls,  and  carries  out  the  treatment  for  all 
such  cases  under  the  direction  of  the  septic  attending  physician.  This 
septic  subdivision  of  the  service  takes  charge  of  all  cases  of  conjunctivitis, 
of  suj>]mrating  umbilicus,  and  of  postpartum  fever.  The  members  of  the 
resident  statf  ])erform  this  duty,  serving  in  rotation  for  periods  of  one 
month  each. 

The  attending  physicians  and  their  assistants  are  engaged  in  private 
jM'actice  as  well  as  in  the  work  of  the  IIos])ital.  They  cannot  always  be 
free  from  the  care  of  private  cases  of  a  suspicious  nature.  These  members 
of  the  IIos]utal  staff,  however,  appreciate  the  ]iarticular  need  of  extra  care 
in  their  antiseptic  ])recautions,  and  can  be  relied  u])on  to  disinfect  their 
hands  \vith  an  intelligent  application  of  the  routine  procedures.  The  IIos- 
])ital  does  not  demand,  even  of  its  officers,  however  skilful  in  ase]>sis,  that 
they  do  aseptic  and  septic  work  in  its  service  at  the  same  time.  The 
attending  ])hysicians  serve  in  rotation  for  periods  of  one  month.  During 
the  month  following  their  month  of  regular  service,  they  become  the  septic 
attending  physician.  This  officer  and  his  assistant  and  the  se])tic  member 
of  the  resident  staff  form  the  septic  department  of  the  Hospital. 

A  further  means  of  preventing  infection  is  to  limit  the  number  of  vagi- 
nal examinations  in  each  case.  A  number  of  observers  have  recently 
claimed  that  normal  labor  should  be  conducted  with  no  internal  examina- 
tion, and  have  presented  series  of  cases  so  treated  in  whom  a  lower  percent- 
age of  morbidity  was  observed  than  in  similar  cases  Avhere  examinations 
were  allowed.  The  percentage  of  fever,  it  is  claimed,  is  proportional  to 
the  numljer  of  such  examinations.  The  following  list  gives  the  ])ublished 
morbidity  records  of  a  number  of  institutions.  In  every  case  100.4  degrees 
Fahi-enheit  (38  degrees  Centigrade)  is  assumed  as  the  limit  of  normal  tem- 
perature. 

AIoiiniDnv  Statistics  ok  Different  Ot.stktrk!  Schools. 

Schools  allowing  students  to  examine  the  patients: 

r^  Fever  from 

Cases. 

all  Causes. 

1.  University  Frauenkliuik,  TIcrlin,  1S8S-1S95...      8,528..      25.5^(39.1^) 

2.  T'niversity  Fraucnklinik,  Dorjxit,  1888-18U3  .  .         889..      14.39^ 
:;.    ('niversity  Obstetric  Clinic,  Prag,  1887-1895. .     8,924. .     13.54^ 

4.  Tniversity  Fraucnklinik.    Lcip/.in-.  isitc, 5115..      2T.U(),< 

5.  Mai.son  d'Accouchements    Ijaiideioccjuc,   Taris, 

1895   2,043.  .      19.18^ 

Infection  Fever. 

6.  University  Friiucnkliiiik-    (I'dikliiiik  i.    Doi-pnl. 

1893 l.'jno..      14. Im;^' 


ASEPSIS,    iMORBIDITY,    AND    MORTALITY.  229 

Fever  from 
all  Causes. 

7.  University  Frauenklinik,  TViirzburg 3,000. .       9.2^ 

8.  Konigliche  Frauenklinik  (Dresden),  1893: 

a.  no  douche  +  examination a.    71.  .a.    4.3^ 

I.    +  douche  +  examination h.  300.  .h.  IS. 67 fo 

e.    +  douche  +  examination e.  419.  .c.  IS.Sfo 

Series  of  cases  conducted  without  internal  examination  : 

Fever  from 
v-^ases.         n  /-I 

ail  Causes. 

9.  University  Frauenklinik,  Leipzig,  1896 1,034.  .     25.26^ 

10.  Konigliche  Frauenklinik,  Dresden,  1893: 

a.  no  douche;  no  examination a.  336.  .a.    5.95^ 

I.    +  douche;  no  examination b.  100.  .1.  ll.Ofo 

c.    4-  douche;  no  examination c.  381.  .c.  12.3,^ 

1.  Zur  puerperalen  Infection.  Koblanck,  Zeitschrift  fiir  Geburtshiilfe  unci  Gynae- 
kologie,  1896. 

6,  2.  Ber-ichte  und  Arbeiten.     O.  Kiistner,  1894. 

3.  Bericlit  liber  die  Morbiditats-  und  Mortalitats-verhaltnisse  auf  der  Geburtshiilf- 
lichen  Klinik  von  Prof.  Pawlik,  etc.,  in  Prag.  Pipek,  Monatsclirift  fiir  Geburtshiilfe 
und  Gyna3kolog'ie,  1896. 

9,  4.  Bakteriologie  des  weiblicben  Genitalkanales.     Menge  und  Kronig,  1897. 

5.  Fonctionnement  de  la  Maison  d'Accoucbements  Baudelocque.     Lepage,  1896. 

7,  Die  Verliiitung  des  Kindbettfiebers  in  den  geburtshilflicheu  Unterricht  anstal- 
ten.     Hofmeier,  Kliniscbe  Vortrage,  1897. 

8,  10.  Untersuchung  liber  die  Entbehrlichkeit  der  Scbeidenaussplilungen  bei  ganz 
normalen  Geburten  und  liber  die  Sogenannte  Selbstinfection.  Leopold.  Arcbiv  fiir 
Gynaekologie,  1894. 

This  agitation  has  had  the  beneficial  effect  of  enlarging  the  field  of 
external  manipulation  and  of  abdominal  palpation.  It  is  the  custom  of 
this  Hospital  to  lunit  the  indications  for  vaginal  examination  to  the  single 
rule  that  some  good  come  of  the  proposed  procedure.  The  Hospital 
demands  of  its  pupils  a  report  concerning  the  condition  of  the  patient  and 
the  progress  of  the  case  at  least  every  two  hours.  Each  such  report  requires 
a  vaginal  examination  to  render  it  complete.  The  first  object  of  this  service 
is  to  teach,  and  it  is  the  unanimous  opinion  of  the  Medical  Board  that  a 
student  must  make  frequent  examinations  of  women  in  all  stages  of  labor 
and  pregnancy  in  order  to  learn  to  appreciate  the  normal  and  abnormal 
phases  of  any  particular  case.  The  students  are  not  given  an  uncontrolled 
freedom  to  examine  the  patients,  but  are  taught  that  frequent  examination 
increases  the  danger  of  infection,  and  that  one  long  examination  is  less 
dangerous  than  two  short' ones.  They  are  taught  also  the  advantage  and 
practice  of  external  examination.  The  table  given  above  shows  that  the 
morbidity  record  of  this  Hospital  compares  favorably  with  that  of  any  of 
the  services  which  include  a  similar  number  of  cases,  whether  the  material 
is  used  for  teaching  purposes  or  not,  and  whether  internal  examination  is 
limited,  omitted,  or  practised  freely. 


230  REPORT   OF   THE   SOCIETV   OF   THE    LYING-IN    HOSPITAL. 

The  statistics  concerning  vaginal  examinations  have  been  recorded  in  a 
can'ful  manner  in  a  number  of  oases.  These  figures  are  detailed  in  the 
statistical  synoj)sis  of  tlie  jjatients.  The  summarv  shows  that  the  pui)ils 
liave  made  27,093  examinations  in  the  first  stage  of  labor  on  5,109  women, 
an  average  of  over  five  examinations  in  each  case.  It  shows,  concerning 
the  second  stage  of  labor,  that  the  ])upils  made  22,<')2T  vaginal  examinations 
on  5,843  cases,  an  average  of  nearly  four  examinations  of  each  parturient 
woman.  In  spite  of  this  extensive  use  of  the  material  for  instruction,  the 
morbidity  jjcrcentage  is  12.20  per  cent.,  and  the  inortality  record  of  all 
cases  dying  of  sepsis  is  0.14  per  cent. 

The  ])ersonal  disinfection  of  tlie  obstetrician  involves  the  questions  of 
dress  and  of  hand  washing.  This  Hospital  does  not  furnish  an  o})erating 
gown  for  the  use  of  those  avIio  conduct  the  normal  cases  of  labor  in  the 
(jutdoor  service,  though  a  gown  is  sometimes  worn  when  an  operation  of 
considerable  importance  is  to  be  performed.  On  such  occasions  a  gown  of 
the  annexed  ])attern  is  borrowed  from  the  indoor  service  (Fig.  14).  For 
the  regular  work,  the  accoucheur  removes  his  coat  and  rolls  up  both  shirt- 
sleeves above  the  elbow.  The  same  preparation  is  made  both  to  examine 
pregnant  women,  to  attend  those  in  labor,  and  to  care  for  the  ])ostpartum 
cases.  His  remaining  efforts  are  applied  to  the  care  needed  to  cleanse  and 
])re])are  the  hands. 

The  students  are  not  allowed  to  attend  the  patients  of  this  hos})ital  when 
their  hands  are  the  seat  of  any  suppurating  wounds.  The  following  details 
a])]ily  to  the  preparation  of  the  hands  of  the  attending  physicians  and  other 
officers  of  the  Institution.  The  care  given  to  tlie  hands  at  all  times  is  an 
important  element  in  rendering  them  easy  of  disinfection  when  desired. 
All  wounds  sliould  be  so  treated  that  they  will  heal  (luickly.  If  small 
lesions  suppurate  and  it  is  necessary  for  one  to  o})erate,  the  hands  are  ren- 
dered aseptic  by  cauterizing  with  liquefied  carbolic  acid  and  the  use  of  extra 
precautions  in  cleansing.  Slight  wounds  Avliich  are  heahng  in  a  cleanly 
manner  are  protected  from  infection  by  a  collodion  dressing,  Avhich  permits 
of  tlie  use  of  the  disabled  hand.  The  wound  is  first  cleansed  with  bichloride 
solution  and  then  covered  with  a  solution  of  iodoform  in  ether.  After  this 
has  eva])orated,  a  very  thin  layer  of  al)sorbent  cotton  is  ])laced  over  the 
wound  and  tlie  whole  surface  is  ])ainted  witli  collodion.  This  di'ies  in  the 
meshes  of  the  cotton,  and  th(!  wliolo  mass  makes  a  tough  waterproof  pellicle, 
wliich  can  be  scrubbcfl  with  a  nail  brush  without  dishKlmno-  it  and  without 
irritation  of  the  wound.  The  fingci-  nails  are  the  most  dilficult  parts  of  the 
hand  to  Ix;  made  aseptic,  and  thcii-  prophylactic  care  is  of  considerable 
iniportaiK-c.  The  fold  of  skin  at  the  base  of  the  nail  and  the  reentering 
angh*  uiidcr  the  frci;  border  demand  the  most  attention.  The  best  ti'eat- 
ment  for  this  fold  of  skin  is  to  kee[)  it  ])ushed  \y.\ck  I'loni  the  nail  and  to 
remove  all  liang-nails  and  roughnesses.  The  )>olislied  surlace  of  the  nail  is 
kept  free  from  tin;  thin  (^pidci-nial  layers  which  ^row  u))on  it  from  the  basal 
fold.  This  is  done  by  scra]»in<^-  the  inoistenc(l  linger  witii  a  sliarj)  stick  or 
quit(!  dull  metal  |)oint.  Tare  is  taken  not  to  sci-atch  the  sui-face  and  thus 
make  a  lodging  i)lace  for  germs.     The  fold  is  jtushed  back  several  times  a 


Fig.  14. — Operating  Gown. 


ASEPSIS,    MORBIDITY,    AND    MORTALITY.  331 

day,  when  the  hands  are  washed ;  and  the  scraping  is  done  thoroughly,  but 
not  oftener  than  once  in  ten  days.  The  free  end  of  the  nail  is  a  natural  dirt 
collector  ;  it  is  best  cleaned  by  the  use  of  a  nail  brush,  soap  and  water,  and 
subsequently  of  a  soft  wooden  point.  A  soft  towel  or  linen  handkerchief 
is  used  for  this  purpose,  pushing  the  cloth  under  the  nail  with  a  nail  of 
the  other  hand.  Metal  scrapers  are  avoided,  because  they  scratch  the  nail 
and  make  crevices  which  collect  dirt  more  readily  and  render  the  nails  more 
difficult  of  mechanical  cleaning  than  they  were  before.  The  ideal  condition 
is  one  in  which  the  under  surface  and  edge  of  the  free  end  of  the  nail  are 
as  smooth  and  polished  as  the  exposed  surface.  The  following  rules  apply 
to  all  attendants,  including  the  students: 

Before  beginning  to  disinfect  the  hands,  any  rings  should  be  removed 
from  the  fingers,  the  coat  should  be  laid  aside,  and  the  shirt-sleeves  rolled 
up,  as  already  described.  The  routine  procedure  of  this  Institution  for 
preparing  the  hands  is  as  follows : 

1.  Wash  with  hot  water,  green  soap,  and  nail  brush  for  at  least  three 
minutes. 

2.  Rinse  in  clear  water,  and  remove  from  under  the  nail  all  visible  dirt 
by  means  of  a  towel,  handkerchief,  or  wooden  point. 

3.  Wash  again  with  a  fresh  supply  of  hot  Avater,  green  soap,  and  nail 
brush  for  at  least  two  minutes. 

4.  Rinse  ofl  the  soap,  and  scrub  the  hands  with  a  solution  of  bichloride 
of  mercury  of  a  strength  of  1  to  2,000,  using  nail  brush  for  at  least  three 
minutes. 

5.  While  using  the  nail  brush,  the  fingers  are  separated  and  particular 
attention  is  given  to  the  nails. 

6.  The  finger  or  hand  is  brought  into  contact  with  the  female  genitals 
while  wet  with  the  bichloride  solution,  and  no  lubricant  is  used. 

In  case  the  hands  of  the  operator  are  known  to  have  been  recently 
infected,  extra  antiseptic  precautions  are  used.  A  thorough  scrubbing  with 
brush  and  alcohol  is  interposed  between  procedures  3  and  4  on  the  list  just 
given.  This  has  been  shown  by  a  number  of  investigators  to  be  very 
effective.*  Sometimes  a  scrubbing  in  a  solution  of  permanganate  of  pot- 
ash, followed  by  a  decolorizing  wash  in  oxalic  acid  solution,  is  used  between 
procedures  2  and  3  of  the  regular  list.  These  extra  procedures  are  used 
by  the  attending  staff  when  they  are  conscious  that  they  have  been  exposed 
to  any  infectious  material. 

The  preservation  of  the  hands  in  an  aseptic  condition  after  they  have 
been  prepared  is  a  question  of  habit.  A  single  touch  by  the  hand  of  some 
unclean  article  may  render  the  work  of  the  past  ten  minutes  entirely  worth- 
less. The  habit  of  refraining  from  such  contaminations  is  acquired  only  by 
continued  practice.  It  is  equally  important  that  an  operator  may  know 
when  his  aseptic  hand  has  inadvertently  touched  some  suspected  article,  be 
it  some  piece  of  furniture  or  some  part  of  his  own  dress  or  of  himself.  It 
is  not  uncommon  to  have  to  stop  some  student  from  making  an  examination 

*  Versuche  tiber  die  Desinfection  der  Haude.  Poten.  Monatschrift  ftir  Geburts- 
liiilfe  und  Gynajkologie.     1895. 


!>3-2  REPORT   OF   THE   SOCTETV    OF   THE    LYING-IX    HOSPITAL. 

until  he  shall  have  resterilized  his  hand  because  he  has  handled  the  chair 
lie  will  sit  in  or  has  readjusted  his  eyo-g-lasses,  or  has  done  some  equally 
unclean  act. 

Bacterioloo^ical  examinations  of  the  hands  of  students  which  have  been 
])rei)ared  in  this  manner  have  ii'iven  in  certain  cases  rather  unsatisfactory 
results.  In  one  series  of  eight  liamls  the  cultures  from  one  only  remained 
sterile;  six  showed  the  presence  of  sta])li}l«x'Occus  albus;  and  those  from 
two  showed  the  ]>resence  of  staphylococcus  citreus.  During  the  period 
when  this  particular  test  was  made,  the  outdoor  service  was  running 
smoothly,  and  the  cases  were  particularly  free  from  infection  and  other 
fevei*s. 

Asepsis  or  Patient. 

The  work  of  Doderlein*  and  Kronigf  has  proved  that  the  normal 
secretion  of  the  vagina  will  not  only  prevent  the  growth  of  pathogenic 
o-erms,  but  also  destroy  those  artificially  introduced.  This  Hospital  treats 
its  ])atients  in  accordance  with  this  truth  and  submits  them  to  no  routine 
]n-oi-)hvlactic  antisepsis  until  labor  has  begun.  Preventive  treatment  is 
applied,  however,  in  special  cases.  All  pregnant  women  who  ])resent  any 
inrtammation  which  could  cause  infection  at  time  of  labor  are  treated.  Any 
sup])iirative  disease  in  the  region  of  the  genital  tract  receives  the  necessaiy 
antiseptic  treatment,  and  an  effort  is  made  to  cure  such  local  inflammations 
as  early  during  pregnancy  as  possible.  Inflammations  of  the  vagina,  blad- 
der, urethra,  vulva,  and  neighljoring  glands,  whether  gonorrhoeal  or  septic 
in  nature,  require  sucli  interference.  Abscesses  are  opened  and  dressed 
antisepticallv.  Vaginitis  and  cystitis  are  treated  with  disinfectant  or 
astringent  irrigation,  and  syphilis  is  treated  by  specific  medication,  botli  in 
the  intei-est  of  the  mother  and  of  the  child. 

The  regular  bathing  of  the  whole  body  and  the  ])roper  regulation  of 
the  bowels  are  sadly  neglected  by  the  dwellers  in  New  York  tenements. 
In  the  (outdoor  service  these  lapses  in  the  rules  of  ordinary  hygiene  must 
usually  be  corrected  during  or  after  labor.  The  application  of  aseptic 
l)rinciples  in  the  outdoor  department  also  meets  with  the  practical  limita- 
tion that  a  considerable  number  of  our  patients  do  not  apply  for  aid  until 
labor  has  begun.  Those  who  may  apply  during  pregnancy  are  thoroughly 
examined,  and,  if  found  to  be  healthy,  they  are  protected  from  a  sul)se- 
quent  '••  auto-infection  ''  so-called,  by  the  rules  pertaining  to  vaginal  exam- 
inations. AVhcncver  internal  examinations  of  pregnant  women  are  made 
in  this  Hospital,  the  same  precautions  in  cleansing  the  liands  ai-o  enforced 
as  wlum  a  case  in  labor  is  to  be  examined. 

The  routine  j)re])a)"ition  of  a  ])atient  for  noi'uial  laboi-  is  limited  to 
external  disinfection.  As  soon  as  the  \m\n\  ;ii  rives  at  the  case,  and  before 
any  ))liysical  examination  is  ma<l<',  tlic  vulva  and  the  mons  veneris,  the 
anal  rcnon  and  jx'rincuni  are  washed  with  soa])  suds,  Avatcr,  and  absorbent 
cotton;  the  same  attention  is  given  t(.  llx-  folds  of  the  nates,  the  groins, 

*I)!iHS.-licid«-iiH<'kn't  unci  sfiiic  Bfdfiitmitr  fiii- das  rncr))('i-iilli('l)cr.    DodoHoin,  1892. 
t  BakUii'iologie  des  weiblicheu  Genitalkaualcs.     Men{,^e  uixl  Kr<)ni{r,  ]K1)7. 


ASEPSIS,    MORBIDITY,    AND    MOETALITY.  233 

the  inner  parts  of  the  thighs,  and  the  lower  part  of  the  abdomen.  The 
hair  of  the  hibia  majora  and  raons  veneris  is  not  cut  in  normal  cases, 
except  for  special  reasons  (excessive  length  or  matted  dirt).  The  soap  is 
washed  off  -with  clean  water,  and  the  whole  region  is  rubbed  with  a  cotton 
wipe  and  rinsed  off  with  bichloride  of  mercury  solution.  If  necessary,  the 
vulva  is  held  closed  while  the  antiseptic  solution  is  being  poured  over  it. 
Such  a  disinfection  is  repeated,  if  the  patient  should  have  a  passage  from 
the  bowels,  or  in  prolonged  labor,  at  intervals  of  six  hours.  The  healthy 
internal  genitals  receive  no  antiseptic  treatment  whatever,  and  for  two 
reasons :  first,  it  is  unnecessary,  and,  secondly,  it  does  positive  harm.  The 
removal  of  mucus  and  the  constringency  of  the  vagina  resulting  from  an 
efficient  disinfection  increase  the  liability  to  abrasions  of  the  mucous  mem- 
brane and  to  perineal  lacerations.  In  cases  where  the  vagina  is  already 
infected,  a  mechanical  or  chemical  disinfection  is  rarely  a  possibility  within 
the  time  limit  of  a  first  stage  of  labor,  and  the  lesions  resulting  from  a  too 
free  scrubbing  will  give  the  germs  Avhich  may  be  present  a  better  eviron- 
ment  for  their  growth.  Internal  disinfection  is  a  doubtful  expedient  after 
labor  is  begun,  and  has  been  discarded  in  our  outdoor  service. 

The  art  of  bringing  the  sterile  hand  into  contact  with  the  vagina  after 
the  patient  has  been  washed  is  easily  acquired.  The  hands  are  prepared 
as  already  described,  and  are  introduced  into  the  vagina  while  still  wet 
with  the  bichloride  solution,  and  without  lubricant.  The  patient  is  exposed 
by  some  assistant  sufficiently  so  that  the  vulva  may  be  seen  and  the  hands 
reach  it  without  touching  either  bed  clothes  or  patient's  garments,  thighs, 
or  perineam.  With  the  thumb  and  forefinger  of  one  hand  the  labia  majora 
are  separated  until  the  introitus  vaginae  is  seen.  The  fore  and  middle  fin- 
gers of  the  other  hand  are  placed  in  this  opening  and  inserted  into  the 
vagina.  The  introduction  of  the  finger  into  a  vagina  by  touch  alone, 
under  the  bed  sheet,  is  a  surgically  unclean  act. 

During  the  final  act  of  expulsion,  the  patient  demands  the  constant 
attendance  of  the  accoucheur.  As  alread}^  explained,  the  patient  is  placed 
on  her  left  side,  and  the  attendant  controls  the  advance  of  the  occiput 
and  the  stretching  of  the  perineum  with  aseptic  hands.  The  hands  are 
rinsed  frequently  in  the  sublimate  solution,  and  are  brought  into  contact 
only  with  the  vulva  and  perineum  and  with  the  neighboring  parts  which 
have  been  disinfected.  As  soon  as  the  presenting  part  has  reached  the 
perineum,  all  reason  for  internal  examination  has  ceased  to  exist.  It  is 
during  this  stage  that  frequent  examinations  and  the  introduction  into  the 
vagina  of  astringent  chemicals  will  be  especiall}^  liable  to  cause  tears  of 
the  soft  parts.  The  labor  can  be  finished  by  external  manipulations  alone. 
The  third  stage  of  labor  will  frequently  terminate  spontaneously ;  if  not, 
the  delivery  of  the  placenta  may  be  effected  by  expression,  after  the  manner 
known  as  that  of  Crede. 

The  immediate  postpartum  treatment  consists  of  a  hot  vaginal  douche 
of  bichloride  of  mercury,  1  to  8,000.  The  fundus  of  the  uterus  is  held  for 
one  hour  before  any  abdominal  bandage  is  applied.  The  external  genitals 
are  cleansed,  with  the  antiseptic  solution,  of  all  visible  blood  stains,  and  a 


234  REPORT   OF   THE    SOCIETY    OF   THE    LYIXG-IN    HOSPITAL. 

viilva  pad  is  placed  on  them.  This  vaiiinal  douche  is  given  as  routine,  not 
so  much  because  of  its  antise})tic  qualities,  but  because  it  lessens  the  chances 
of  hivmorrhage  from  the  uterus.  The  vulva  })ad  used  in  the  out-patient 
de])artment  is  a  small  flat  dressing,  and  cannot  be  described  as  in  any  sense 
an  "occlusive  antise])tic  dressing."  The  pads  must  be  loosened  by  the 
])atients  themselves  whenever  they  pass  urine;  they  collect  a  samj^le  of 
the  lochia  for  the  instruction  of  the  student  attendant,  and  prevent  only 
imperfectly  the  access  of  germs  to  the  external  genitals. 

All  |)atients  are  visited  twice  daily  for  three  days  after  labor,  and  once 
daily  after  the  third  day  until  discharged.  At  these  postpartum  visits  the 
stutient  uses  the  same  precautions  for  his  personal  disinfection  that  are 
required  at  the  coniluction  of  a  labor.  He  washes  the  external  genitals  of 
the  wonuui  with  absorbent  cotton  and  antiseptic  solution  (bichloride  of 
mercury,  1  to  2,(»oo);  he  changes  the  v^ulva  pads;  he  washes  the  chiUrs 
mouth  and  eyes  Avith  boracic  acid  solution,  and  he  dresses  the  stuni])  of  the 
umbilical  cord  or  the  umbilical  wound  with  fresh  gauze  and  sterilized 
starch  powder.  The  rest  of  his  duties  are  detailed  elsewhere.  They  are 
concerned  with  the  patient's  general  condition,  and  are  not  to  be  classified 
as  "antisepsis.''  The  internal  genitals  receive  no  douches  or  other 
routine  treatment.  The  general  rnle  that  postpartum  asepsis  is  limited 
exclusivelv  to  external  cleanliness  has  no  exceptions  but  for  special  cause. 

In  complicated  laljor  the  immediate  antepartum  preparation  is  usually 
more  thorough  than  it  is  in  normal  cases.  The  external  genitals  receive 
a  careful  scrubbing  with  soa])  and  water  and  nail  l)rush,  and  the  ])udendal 
hair  is  cut  short  or  even  shaved.  After  such  a  scrubbing,  the  routine  rins- 
ing with  corrosive  sublimate  solution  is  repeated.  Such  an  antiseptic  toilet 
is  thorough  enough  to  be  distinctly  painful,  and  is  usually  done  after  the 
patient  is  under  the  influence  of  an  anajsthetic.  Even  in  these  operative 
ca.ses,  the  internal  genitals  are  not  given  any  speciflc  treatment,  but  all 
intra  vaginal  and  intrauterine  manipulations  are  undertaken  in  or  through 
the  normal  vagina. 

The  aseptic  use  of  instruments  during  operations  and  the  prevention  of 
infection  at  the  field  of  operation  require,  in  a  tenement-house  service,  a  per- 
fect familiarity  with  the  environment  on  the  part  of  every  one  who  may 
take  an  active  ])art  in  the  pro])osed  procedure.  AVhenever  an  operation  is 
necessary  in  tlu?  outdoor  service  of  this  Hospital,  tlie  members  of  the 
attending  ;ind  i-csidcMit  staffs  alone  take  part  in  the  active  Avork;  tlie  jnipils 
are  deposcij  to  the  position  of  s])ectators,  or,  at  most,  to  j)assive  assistants,  to 
hold  a  leg  or  douche  bag.  The  instruments  are  spread  out  on  the  towels  in 
which  th«;y  were  sterilized.  The  ])atient  is  ana>sth(^tized  and  ])laced  uj)on  the 
improvised  (Operating  table.  iShe  is  then  subjected  to  the  antisej)tic  })repa- 
ration  alrcaxly  described,  and  the  field  of  operation  is  surrounded  with  the 
towels  which  were  brought  in  a  sjiecial  sti^'ilized  bundle.  The  legs  and 
feet,  the  upper  ])art  of  the  abdonuMi,  and  th(5  table  beneath  the  ])atient's 
butttxiks  are  covered  with  these  sterilized  towels.  All  efforts  are  concen- 
trated on  tliese  three  elements — the  opcjrator,  the  |)aticnt,  and  tlic;  instru- 
ments— and  tlie  more  remote  surronntUngs  arc  ign<jr<;d  <'ntirely.     The  Hos- 


ASEPSIS,    MORBIDITY,    AND    MORTALITY.  235 

pital  is  very  ]mrticular  to  see  that  all  patients  receive  plenty  of  good, 
nourishing  food  to  assist  them  to  recover  from  the  strain  of  childbirth.  A 
small  diet  kitchen,  run  in  connection  with  the  Hospital,  is  a  great  assistance 
to  prevent  a  serious  ending  to  many  operative  cases. 

The  immediate  postpartum  treatment  of  patients  who  have  been  oper- 
ated upon  is  changed  from  that  given  the  normal  cases  onl}^  in  the  addition 
of  an  intrauterine  douche  immediately  after  the  delivery  of  the  placenta. 
This  douche  acts  as  a  stimulus  to  uterine  contraction  as  much  as  it  is  an 
aseptic  measure.  The  external  genitals  receive  the  same  care  as  in  routine 
cases.  The  postpartum  care  of  operative  cases  presents  practical  peculiari- 
ties of  asepsis  in  only  a  few  cases.  When  the  uterus  has  been  packed  with 
gauze,  it  is  emptied,  as  a  rule,  within  three  days,  or  as  soon  as  the  woman's 
temperature  and  pulse  would  indicate  an  absorption  of  septic  material. 
When  a  perineorrhaphy  has  been  done,  the  patient  may  require  catheteriz- 
ation at  intervals  of  eight  hours  for  two  days  or  longer.  Such  cases  may 
suffer  from  retention  for  a  variable  period,  and  they  may  not  get  out  of  bed 
because  of  the  wound  in  the  perineum,  hence  the  catheterization  may  be 
required  for  a  longer  period.  The  stitches  are  removed  from  the  perineal 
wound  on  the  eighth  to  tenth  day.  The  passing  of  a  catheter  in  normal 
cases  is  a  last  resort  and  rarely  needed.  Such  patients  are  allowed  to  sit  up 
and  empty  the  bladder  without  assistance.  The  aseptic  method  of  passing 
a  catheter  as  practised  in  this  Hospital  has  been  described  above. 


Morbidity  Statistics. 

The  last  Medical  Report  of  this  Hospital,  published  in  1893,  contained  a 
study  of  those  cases  of  the  preceding  three  years  which  were  complicated 
by  febrile  symptoms.  The  following  analysis  is  founded  upon  a  six  years' 
service  in  the  Hospital's  outdoor  department,  and  includes  the  period  cov- 
ered by  the  report  of  1893.  The  definition  of  fever  which  was  arbitrarily 
assumed  in  that  Report  will  be  adhered  to  in  this,  and  every  rise  of  tem- 
perature above  100.4  degrees  Fahrenheit  is  included  as  of  pathological 
significance.  The  temperatures  are  all  taken  beneath  the  tongues  of  the 
patients  by  a  self -registering  thermometer,  which  is  left  in  situ  for  a  full 
five  minutes. 

During  these  six  years  the  Hospital  has  treated  10,233  women  in  their 
homes,  of  whom  1,255  have  presented  a  febrile  complication;  a  total  fever 
or  morbidity  percentage  of  12.26  per  cent.  This  is  a  better  showing  than 
was  made  in  the  1893  Report,  where  this  figure  was  noted  as  15.81  per 
cent.  This  improvement  is  due  in  part  to  the  fact  that  the  early  period  of 
1,454  cases  described  below  now  makes  up  a  lesser  part  of  the  total  num- 
ber of  cases.  It  is  partly  due  also  to  improved  methods  of  asepsis  in  hand- 
ling this  service.  The  six  years  are  easily  divided  into  three  periods,  accord- 
ing to  the  varying  conditions  of  the  service. 


236  REPORT   OF   THE   SOCIETY   OF   THE   LYTXG-IX   HOSPITAL. 

Table  I. 

THREE    PERIODS    OF    SERVICE. 

I.  JiUKutri/  18,  1S90,  to  Mapch  1,  1892. 

Patients  aclmitted  to  treatment  in  all  stages  of  puerperal  period,  \vliether 
infected  or  not.  Service  entirely  out-initient;  1,45-1  cases  gave  310  cases 
of  fever,  or  21.78  per  cent. 

II.  MarrJi   1,  18'.t2,  to  FSnianj  18,  1895. 

Patients  admitted  to  treatment  only  ante])artnm,  or  when,  unattended 
in  labor,  they  have  applied  ^vithin  12  hours  of  delivery.  No  postpartum 
infected  cases  taken.  Service  entirely  out-patient;  0,45()  cases  gave  732 
Ciises  of  fever,  or  11.33  per  cent. 

III.  Fihruarij  18,   1895,  to  Ajjrll  1,  1896. 

Out-patient  service  the  same  as  in  the  second  period;  but  the  indoor  ser- 
vice was  open,  and  many  severer  cases  were  transferred  from  the  outdoor 
to  the  indoor  service.  The  cases,  therefore,  in  this  period,  have  been  less 
complicated  than  in  second  period;  2,323  cases  gave  207  cases  of  fever,  or 
8.91  per  cent. 

The  percentage  given  above  for  the  first  period  differs  from  the  same 

ratio  as  given  in  the  last  Report  of  the  Hospital.     Since  the  date  of  the 

last  Ileport  the  original  histories  have  been  subjected  to  a  careful  review, 

with  the  result  that  a  number  of  cases  of  fever  of  lesser  degree  have  been 

discovered  and  added  to  the  list.     The  morbidity  percentage  for  the  1,45-4 

cases  of  this  period  has  been  increased  from  20.70  percent,  to  21.73  per 

cent.     The  difference  in  the  percentages  for  the  second  and  third  periods, 

and  the  influence  of  the  indoor  service  upon  the  morbidity  percentage  of 

tlie  (jutdoor  statistics,  will  be  appreciated  after  a  glance  at  the  following 

table,  which  presents  a  list  of  the  severer  cases  transferred  from  the  latter 

service  to  the  indoor  wards. 

Table  II. 

Cases. 

Manual  dilatation  and  version  for  placenta  praevia 3 

Version  for  shoulder  ])resentation 2 

Deca]>itation  for  shoulder  presentation 1 

Craniijtomy  for  contracted  pelvis 1 

Craniotomy  for  liydrocephalus 1 

Forceps  for  posterior  occipital  position 1 

Forceps  for  breech  presentation 1 

Postpartum  case  for  endocarditis 1 

IVjstpartuin  cases  for  oclani])sia 2 

Posti)artuni  cases  lor  i-iipturc  of  utci-us 2 

In  addition  a  number  of  cases  wliicli  presented  the  possibility  of  opera- 
tive jirocedure  at  the  time  of  their  a])])li(;;ition  have  been  enrolled  on  the 
indoor  books  at  once;,  without  tlie  formality  of  an  outdoor  service  registry. 
The  list  just  given  represents  the  cases  actually  transferred  after  laboi*  liad 
begun.       A    number  of   |»rimi|)ar;e  also  have  l)een  1  rai)sfeiTe(]  t,i>  tin;  ward 


ASEPSIS,    MORBIDITY,    AND    MORTALITY.  237 

service,  which  represents  a  combined  primipara  and  operative  service.  The 
following  table  will  demonstrate  more  clearly  the  percentage  proportion  of 
fever  occurring  in  successive  periods  of  the  service.  In  this  list  the  10,233 
cases  are  divided  into  series  of  1,000  cases,  and  the  nmnber  of  fever  cases 
and  morbidity  percentage  for  each  period  is  appended : 

Table  III. 

FEVER    PERCENTAGES    BY    SUCCESSIVE    1,000    CASES. 

First  thousand,  209  cases  of  fever,  or. 20.9^ 

Second       "  199  "  "            19.9^ 

Third         "  160  "  "           16.0^ 

Fourth       "  lOr  "  "           10.7^ 

Fifth          "  85  ''  "           8.6fo 

Sixth          "  112  ''  "           11.2^ 

Seventh     "  83  "  "            8.3^ 

Eighth       "  100  "  "           10.0^ 

Ninth        "  92  "  "           9.2^ 

Tenth        "  89  "  "           8.9^ 

233  cases           19  "  "           8.15^ 

10,233  cases  1,255  "  '' 12.26^ 

The  morbidity  percentages  thus  obtained  vary  during  the  more  recent 
periods  between  8.3  per  cent,  and  11.2  per  cent.  These  variations  do  not 
seem  to  follow  any  rule  when  viewed  from  this  basis  of  successive  series  of 
one  thousand  cases.  The  influence  upon  the  morbidity  of  using  a  mater- 
nity ser\^ce  for  the  instruction  of  medical  students  can  be  estimated  in  some 
measure  from  the  following  table.  Most  of  our  pupils  are  busy  at  their 
medical  schools  from  October  1st  to  April  1st,  and  are  comparatively  free 
from  required  work  during  the  summer  six  months.  They  come  to  this 
Hospital  during  the  latter  period  to  take  the  practical  work  in  midwifery, 
which  is  for  theju  an  optional  course.  The  twelve  months  can  be  divided, 
therefore,  into  two  six-month  periods,  according  to  the  number  of  pupils 
on  duty.  During  the  winter  months  the  pupils  are  comparatively  few  in 
number,  and  the  majority  of  the  patients  are  cared  for  b}^  the  trained 
physicians  on  the  house  staff.  During  the  summer  months  the  patients  are 
used  for  teaching  purposes  to  their  fullest  possible  extent. 

In  the  following  table  the  number  of  students  on  duty,  the  number  of 
patients  delivered,  the  number  of  fever  cases  occurring  in  these  cases,  and 
the  morbidity  percentage  are  given  for  the  first  period  of  nine  months  and 
for  each  six  months'  period  thereafter,  beginning  with  the  date  of  opening 
of  the  outdoor  service.  This  table  shows  plainly  that  the  morbidity  is  not 
proportional  to  the  number  of  students  instructed,  and  therefore  not  to 
the  use  made  of  the  service  for  their  instruction.  It  shows  the  same 
influences  at  work  as  already  pointed  out  in  Table  I.,  but  it  would  seem 
to  indicate,  further,  that  the  parturient  woman  was  more  susceptible  to 
febrile  complications  during  the  cold  months  of  the  year.  Such  a  fact 
would  have  been  dwelt  upon  by  earlier  observers  more  than  it  will  be  by 


238 


REPORT   OF   THE   SOCIETY    OF   THE   LYING-LN    HOSPITAL. 


the  inoilern  obstetrician,  who  thinks  more  of  the  souires  of  septic  infec- 
tion than  of  climatic  intluonces.  Tlie  reason  for  snch  a  condition  in  this 
sernce  can  be  found  in  the  unhygienic  dwellings  and  the  herding  of  peo})le 
in  the  Polish  quarters  of  New  York-— factors  which  operate  to  supply  our 
patients  with  poorer  food  and  more  vitiated  air  in  winter  than  in  summer, 
when  fuel  need  not  be  purchased,  and  when  all  the  windows  may  be  kept 
constiintly  open.  The  fact  renuiins  that  there  is  more  fever  among  our 
patients  during  the  winter  months,  when  the  sources  of  infection  are 
diminished  in  number,  tlian  during  the  warm  weather,  when  the  clinical 
material  is  used  for  instruction  pur})Oses  to  the  fullest  possible  extent. 

Table   IV. 

RELATION    OF    NUMBER    OF    STUDENTS    TO    PERCENTAGE    OF    FEVER. 


Period. 


Jan.  8,  1S90,  to  Sept.  30,  1890,  9  months 

(Jan.  8th  to  Mar.  31st  onlv  15  cases  treated.) 

Oct.  1,  1890,  to  Mar.  31,  1891,  6  months 

Aiu'il  1,  1891,  to  Sept.  30,  1891,  "       . . .  . 

Oct.  1,  1891,  to  Mar.  31,  1892,  "       . . . . 

A]n-il  1,  1892,  to  Sept.  30,  1892,  "       . . .  . 

Oct.  1,  1892,  to  Mar.  31,  1893,  "       . . .  . 

April  1,  1893,  to  Sept.  30,  1893,         "       . . .  . 
Oct.  1,  1893,  to  Mar.  31,  1894,  "       . . . . 

April  1,  1894,  to  Sept.  30,  1894,  "       .... 

Oct.  1,  1894,  to  Mar.  31,  1895,  "       . . . . 

April  1,  1895,  to  Sept.  30,  1895,         "       

Oct.  1,  1895,  to  Mar.  31,  1896,  "       . . . . 


Totals,  6  years  3  months 


cc 

<s> 

w 

u: 

.  <A 

-4-J 

oo 

6  g 

xA 

^l! 

^'3 

^1 

> 

Xfl 

O 

Ph 

53 

130 

25 

♦)2 

201 

49 

145 

470 

96 

140 

819 

176 

204 

1,046 

176 

105 

1,071 

130 

143 

1,144 

95 

GO 

1,025 

114 

206 

1,331 

121 

77 

831 

80 

224 

970 

88 

126 

1,195 

105 

1,545 

10,233 

1,255 

19.23 

24.37 

20.42 

21.48 

16.82 

12.13 

8.30 

11.12 

9.09 

9 .  62 

9.07 

8.78 

12.26 


The  following  tables  of  the  presentations  and  of  the  operations  done 
in  the  service  during  the  period  reported  upon,  reproduce  the  figures  from 
the  statistical  syno])sis,  and  will  give  a  clear  a})preciation  of  the  character 
of  the  .service. 

Table  V. 

TAIU.K    OK    PRESENTATIONS. 

Vertex 8,4!>5  cases,  or  0  1.71'^  of  ol)served  cases. 

Face,    3«;  I 

lirow,    \  r   42     "       "     0.47;^  "          "           " 

Ear,       2  ) 

Breech VA\      ''       "     3.80^  "          "           "■ 

Shoulder 91     "       "     1.02^"          "           " 


ASEPSIS,    MORBIDITY,    AND    MORTALITY.  239 

Tablk  yi. 

TABLE  (W    OPERATIONS  AND  SEVERER  COMPLICATIONS. 

Placenta  prasvia 31  cases,  or  O.SOfo  of  all  cases. 

Eclampsia 14  "  "0.13^  "  " 

Abortions 417  "  "  4.07^  "  '' 

Forceps 204  "  "2.99^  "  "      omitting  abortions. 

Version 212  "  "  2.1G^  "  "             "              " 

Perforation  and  decapita- 
tion   5  "  "  0.05^  "  "             "               " 

Symphysiotomy 6  '•'  "  0.06^  "  "             "              " 

Csesarean  section 2  "  "0.02^  "  "            "              '' 

Manual  extrac. of  placenta,  182  "  "  1.95^^  "  "             "              " 

It  is  an  accepted  fact  that  priraiparfe  are  more  liable  to  febrile  compli- 
cations after  labor  than  multipara  are,  and  it  is  of  interest  to  note  in  this 
connection  that  there  were  2,157  primiparge  out  of  10,094  cases  in  whom 
the  number  of  the  parturiency  was  noted.  This  is  a  percentage  of  21.  Of 
the  1,255  cases  presenting  febrile  symptoms,  403  were  primiparae  and  852 
were  multipara.  The  2,157  primipar^e  represent  only  21  per  cent,  of  all 
cases,  but  furnish  403  fever  cases,  which  is  32.11  per  cent,  of  all  fever 
cases.  These  403  fever  cases  represent  18.68  per  cent,  of  all  primiparge, 
and  the  852  fever  cases  occurring  in  multiparse  represent  only  10.54  per 
cent,  of  all  multiparae.  These  figures  mean  that  the  ratio  10.54  to  18.68,  or 
1  to  1.77,  represents  the  relative  frequency  of  postpartum  fever  in  multiparae 
and  primiparee.  This  ratio  is  given  by  Kleinwachter  as  3.7  to  6.8,  or 
1  to  1.83,  which  is  nearly  identical  with  the  above  result. 

It  has  been  decided  to  divide  the  1,255  cases  which  present  febrile  com- 
plications according  to  their  prominent  etiological  factor  into  seven  classes 
similar  to  those  adopted  in  the  last  Medical  Report.  This  has  been  done  in 
the  following  table : 

Table  YII. 

classification  of  fever  oases  accordina  to  chief  causes. 

Cases.     Of  fever  cases.  Of  all  cases. 

Class  I.  Breast  temperatures 171  13.63^  1.67^ 

Class  II.  Constipation  temperatures. .     276  21.99^  2.70^ 

Class  III.  Combinations  of  I.  and  II.      90  7.17^  0.88^ 

Class  lY.  Puerperal  infection 331  26.38^  3.23^ 

Class  Y.  Complications    which   are  \ 

not  puerperal  sepsis  and  not  in-  V     82  6.53^  0.80^ 

eluded  in  Classes  I.  to  lY ) 

Class  YI.   Single  rise  of  temperature  ]    162  12.91^  1.58^ 

on  labor  day j  (217)  (17.29^)  (2.12^) 

Class  YII.  Temperatures     of      nn- ^^^ 

known  oriffm 


240 


REPORT   OF   THE   SOCIETY    OF   THE    LVIXG-IN    HOSPITAL. 


Class  I.     Cases   in  ^VHICH    the   Breasts   aveke   Hard   and   Tender,  and 
TUE  Temperature  Became  Normal  upon  Relief  of  this  Condition. 

As  recorded  in  Table  VII.  there  were  171  cases.  To  these  cases  there 
must  be  added  one  case  of  abscess  of  the  breast,  in  which  the  abscess  fol- 
lowed a  curetl  uterine  sepsis. 

Analysis  of  the  17l'  Cases  of  Breast  Temperature. 

Table  YIIL 

table  of  maxi:mrm  temperatures. 

Cases. 

Maximum  temperature  between  100.5"  and  101.4° S3 

'-  "  "        101.5°    "    102.4° 41 

''  "  "         102.5°    "    103.4^ 28 

"  "  "         103.5°    "    104.4° IT 

"  "  "         104.5°    "    105.4° 3 

Table  IX. 

TABLE  OF  NUMBER  OF  DAY  POSTPARTUM  OF  ONSET  OF  FEVER. 

Cases. 

Fever  began  on  1st     day  postpartum 9 

"           15 

'             "           39 

29 

"           20 

16 

'             "           12 

13 

i  a  ^ 

'  "  0 


a 

2d 
3d 

4tli 

5th 

6th 

7th 

8th 

9  til 

loth 

nth 

21st 

32d 

Table  X. 

TABLE    OF    DURATION    OF    TEMPERATlIiK. 

Cases. 


Fever  lasted  1  dav 110 


2  days 


19 

8 


Fever  lasted  5  davs , 


Cases. 
6 

1 

2 
1 


Of  these  172  eases  of  teHi])erature  due  to  changes  in  the  breasts,  12 
developed  an  al)Sfess.  To  these  12  cases,  \)  other  cases  of  abscess  of  the 
breast  must  be  added,  in  8  of  which  the  abscess  formation  was  not  accom- 
])aniod  by  any  febrile  symptoms,  and  1  case  in  which  the  aljscess  of  the 
brcjLst  was  ])ya;mic  in  character.  These  21  cases  of  purulent  inflammation 
of  the  mammary  gland  make  up  only  0.2  per  cent,  of  the  total  numl)er 
of  cas<^?s  treat(;d.  This  number  is  reduced  to  0.15  ])er  cent,  if  we  remove 
from  the  total  21  the  pyicmic  ca.se  aiul  I  otluir  cases  w  Iiidi  <)ii;^ii);it('(l  fiom 
an  infection  of  th(,'  ni]i]»les  bcfr)rf'  l;il)()i'  l»c^;in. 


ASEPSIS,    MORBIDITY,    AND   MORTALITY, 


241 


The  following  table  gives  some  interesting  facts  concerning  these  cases : 

Table  XI. 


. 

r^ 

1   ^ 

r- 

CD  ie 

-^^  i^ 

0,3J 

M3 

a  CO 

1^ 

a;  o 

g 
a 

ci 

S8  M 

.g 

-t-i 

be 

a) 

pq 

« 

PmO 

£ 

^ 

M 

^ 

Abscesses  without  fever . 

2 

6 

4 

3 

5 

■1 

4 

' '         with  fever .... 

2 

10 

1 

3 

9 

6 

6 

Pyaemic  abscess 

0 

1 

1 

0 

1 

0 

1 

Totals 

4 

17 

6 

6 

15 

10 

11 

Class    II.     Cases    in   which    the    Bowels    were    Constipated,   and   the 
Temperature  Became  Kormal  upon  the  Exhibition  of  Cathartics. 

There  are  276  cases  which  come  under  this  heading. 

Analysis  of  the  276  Cases  of  Constipation  Temperature. 

Table  XII. 

TABLE    OF    maximum    TEMPERATURES. 

Cases. 

Maximum  temperatures  between  100.5"  and  101.4° 139 

"  "  "        101.5°    "    102.4° 82 

"  "  "        102.5°    "    103.4° 37 

"  "  "        103.5°    "    104.4° 16 

"  "  "        104.5°    "    105.4° 2 


Table  XIII. 

TABLE    OF    NUMBER    OF    DAY    POSTPARTUM    OF    ONSET    OF    FEVER. 

Cases. 
Fever  began  on    1st  day  postpartum 52 


2d 

3d 

4th 

5th 

6th 

7th 

8th 

9th 

10th 

11th 

14th 

15th 


52 

69 

40 

23 

19 

5 

7 

3 

3 

1 

1 

1 


16 


242 


REPORT   OF   THE    SOCIETY    OF   THE    LYIXlMN    HOSPITAL. 


Table  XIY. 
table  of  duration  of  temperature 
Cases. 


Fever  lasted  1  tlay 197 

•  -J  (lays 49 

•  ^5     -     17 


Cases, 
Fever  lasted  4  days 9 

U  ii  K         i(  2 


Class  III.  Cases  in  which  Both  the  Breasts  and  the  Condition  of 
THE  Bowels  Demanded  Treatment,  and  the  Temperature  Became 
Xormal  upon  Believing  These  Conditions. 

There  are  9o  cases  of  which  this  statement  is  true. 

Analysis  of  the  90  Cases  of  Combined  Breast  and  Bowel 

Temperatures. 

Table  XV. 

TABLE    OF    MAXIMUM    TEMPERATURES. 

Cases. 

Maximum  temperature  between  100.5°  and  101.4° 26 

''  "  "         101.5°     "    102.4° 37 

"  "  "         102.5°    "    103.4° 17 

"  "  "         103.5°     "    104.4° 7 

"  "  "         104.5°     "    105.4° 3 

Table  XYI. 

TABLE    OF    NUMBER    OF   DAY    POSTPARTUM    OF    ONSET    OF    FEVER. 

Cases. 

Fever  began  on    1st  day  postpartum 11 

11 


2d 
3d 
4th 
5  th 
Gth 
7th 
Sth 
9th 
loth 
11th 


20 
12 
9 
11 
6 
G 
1 
1 
2 


Cases 

Fever  lasted  1  day 44 

"         **      2(hiys L>o 

••      :;     ••    II 


Taiuj.;  XVII. 

TABLE    OF    I)rHATK)N    OF    TEMPERATURE. 

Cases. 
Fevei-  lasted  4  chtys 7 

"       "     f;    "    3 


ASEPSIS,    MORBIDITY,    AND   MORTALITY. 


243 


Class  IV.     Cases   in    which    the    Temperature    Seemed    to   be  Due  to 
THE    Action    of   Micro-Organisms    which    had   Invaded   the    Body 

THROUGH    the    PaRTURIENT    WoUNDS. 

There  are  331  cases  of  puerperal  infection,  Avliich  give  the   following 
analysis  tables: 

Analysis  of  the  331  Cases  of  Septic  Infection. 

Table  XYIII. 

table  of  maximum  temperatures. 

Cases. 
Maximum  temperatures  between  100.5°  and  101.4° 56 


"         101.5° 

102.4°.... 

...66 

"         102.5° 

103.4°.... 

...64 

"         103.5° 

104.4°. . . . 

...72 

"         104.5° 

105.4°. . . . 

...57 

"         105.5° 

106.4°. . . . 

.  ..   14 

"         106.5° 

106.9°...  . 

...      2 

Table  XIX. 

TABLE    OF    NUMBER    OF    DAY    POSTPARTUM    OF    ONSET    OF    FEVER. 

Cases. 

Fever  began  on  labor  day 60 

1st  day  j)Ostpartum 56 

" 49 

"  48 

"  41 

20 

"  19 

8 

8 

"  8 

"  5 

"  4 

"  1 

''  3 

"  1 


1st 

2d 

3d 

4th 

5th 

6th 

7th 

8th 

9th 

10th 

11th 

12th 

13th 

14th 

These  331  septic  cases  may  be  divided  into  two  groups — those  which 
remained  in  the  care  of  the  Hospital  until  the  end  of  the  disease,  and  those 
which  sought  other  attendance  during  their  illness.  Of  the  first  class,  272 
recovered  and  9  died ;  37  cases  sought  the  aid  of  outside  physicians ;  the 
results  in  34  are  doubtful ;  3  others  have  been  traced,  and  the  final  result 
recorded  in  the  histories.  The  remaining  13  were  transferred  to  other 
hospitals  and  their  record  is  given  below. 

The  tables  of  duration  of  temperature  are  given  separately  for  each 
subdivision. 


244 


REPORT   OF   THE   SOCIETY   OF  THE   LYING-IX   HOSPITAL. 


Taule  XX. 

TABLE    OF    DURATION    OF    TEMPERATURE    IN    272    CASES    OF    GROUP    I.    "WHICH 

l^ECOVERED. 


Fever  lasted 


Cases. 

1  (lay •'.»> 

2  (lays 47 

:)     ••     38 

4  '•     42 

o     •'     2o 

r.    "   IS 

7     ••     12 

5  ••     7 


Cases. 

Fever  lasted    0  days 4 

"         "       10     ''    5 

'^       11     "    1 

"         "       12     "    2 

"         "       13     "    2 

"       15     "    G 

''         "       19     "    2 

"         "       30     "     1 


Table  XXI. 

TABLE    OF    DURATION    OF    TEMPERATURE    OF  9    CASES    OF    GROUP    I.  WHICH    DIED. 


Fever  lasted    3  days 

"         "         5     ''^ 


Cases. 

2 
2 

1 
1 


Cases 

Fever  lasted    8  days 1 

"         "       11     " 1 

"         "       35     " 1 


Table  XXII. 

TABLE    OF    THE   OBSERVED  DURATION    OF    TEMPERATURE    IN  3Y  CASES  OF  GROUP  II. 
AVHO   CALLED    IN    OTHER    PHYSICIANS. 


Cases. 
Fever  observed  1  day 3 

"  '•         2  days 4 

"  ••         3     '•     10 

II  ii         4     "  9 

<<  «<         5     >'  2 


Cases. 
Fever  observed  6  days 3 

u  a  7       "  9 

"  "         8     "     1 

"  '<         9     "    2 

"  '<       12     "  1 


Of  the  13  cases  referred  to  (ttlicr  liospita Is  for  treatment,  9  recovered 
and  4  died.  Tlic  duratioji  of  fcvci-  in  these  cases  is  sliown  in  tlic  followin*^- 
table: 

Taijlk  XXIII. 

STATEMENT    OF    OBSEKVKH    IirilAlIoX    OV    'II;M  I'KliA'IT  IvK  I\    13  CASES  OF  (JUoUl'  II. 
TRANSFERRED     To    OlIIKIi    IK  (SITIALS. 

Fever  was  observed  for  two  days  in  two  cases,  for  live  days  in  two  cases, 
and  for  six,  seven,  eleven,  tliirt(!en,  and  twenty-oiu;  days  res])ectivcly  in 
one  case  each ;  these  nine  recovered.  Fever  was  observed  for  six  days  in 
three  ca.ses,  and  for  seventeen  days  in  one  ease;  these  four  died  in  hospital. 

.\  THon- drtaijcd  aiialvsis  is  ^n veil  bch)W  coiicci'iiin^'  the  fatal  cases. 


ASEPSIS.    MORBIDITY,    AND   MORTALITY.  245 

Class  Y.  Cases  in  which  the  Temperature  was  Evidently  Due  to 
Some  Complicating  Pathological  Condition  Other  than  a  Puer- 
peral Septicemia. 

There  are  82  such  cases  in  the  series  under  consideration,  and  they  may 
be  grouped  as  follows  : 

Analysis  of  the  82  Cases  of  Complicating  Diseases. 
Table  XXIV. 

GROUP    I.       NON-SEPTIC    DISEASES. 


Cases. 

Pneumonia 16 

Epidemic  influenza  without  pneu- 
monia       4 

Bronchitis 16 

DiT  pleurisy 1 


Cases. 

Phthisis 11 

Malaria 3 

Intestinal  colic 2 

Alcoholism 1 

Starvation 1 


GROUP    II.        SEPTIC    DISEASES    OF    NON-PUERPERAL    ORIGIN 

Cases. 


Facial  erysipelas 4 

Cystitis  1 

Abscess  of  gluteal  region 1 

Abscess  of  thig-h 1 


Cases. 

Cellulitis  of  wrist 1 

Burns  from  douche  and  hypoder- 
mic abscess 1 

Tonsillitis 4 


GROUP    III.       PUERPERAL    DISEASES    OF    NON-SEPTIC    ORIGIN. 

Cases. 

Eclampsia 8 

Suppression  of  urine  after  ether 1 

Retention  of  urine 1 

Anaemia  after  haemorrhage 4 

To  these  there  should  be  added  one  case  of  phthisis  who  died  without 
presenting  febrile  symptoms,  one  case  of  tonsillitis  in  a  patient  who  had 
previously  been  cured  of  a  puerperal  sepsis,  and  ten  cases  of  pneumonia 
which  complicated  septic  processes. 

Adding  these  duplicate  or  additional  cases,  the  following  list  gives  the 
corrected  statistics : 

Cases. 

Pneumonia 26 

Phthisis 12 

Tonsillitis 5 

Class  YI.     Cases  in  avhich  a  Single    Pise  of    Temperature    Occurred 
During  or  Immediately  After  Delivery. 

There  are  162  cases  in  this  subdivision  of  the  subject,  but  there  are  55 
other  cases  which  presented  a  similar  rise  during  or  immediately  after  labor, 
and  also  a  subsequent  temperature  due  to  some  other  cause.     These  217 


246  REPORT   OF   THE   SOCIETY    OF   THE    LYIXG-IX   HOSPITAL. 

cases  are  grouped  for  purposes  of  statistics.  Sixty  aiklilional  cases  pre- 
sented a  temperature  on  the  day  of  delivery  which  was  tlue  to  a  true  se})- 
ticannia:  these  are  considered  under  Chiss  IV.  only. 

The  etiological  factor  in  this  class  of  cases  is,  that  labor  is  accompanied 
by  an  inci-eased  muscular  exertion,  with  a  diminished  activity  of  the  lungs 
and  skin.* 

Analysis  ok  tuk  :^17  Cases  of  Labor  Day  Temperatures. 

Table  XXY. 
table  of  causes  of  seooxd  fever  ix  55  additional  cases. 

Cases. 

Fever  due  to  breasts 11 

''  "    constipation 20 

"  "    both  breasts  and  Ijowels 10 


u 


sepsis 


"  "    unknown  causes  .    < 

Table  XXYI. 

table  of  height  of  temperature, 

Cases. 

Temperature  between  100.5°  and  101.4^ 182 

"                  "         101.5°    "    102.4° 30 

"                  "         102.5°    "    103.4° 3 

"                  "         103.5°     "    104.4° 2 

Class  VII.     Cases  in  which  no  Accountable  Cause  for  the  Temperature 

WAS  Obvious. 

There  are  143  cases  of  this  class. 

Analy'sis  of  the  143  Cases  of  Temperature  of  Unknown  Origin. 

Table  XXVII. 

TABLE    OF    maximum    TEMPERATURES. 

Cases. 

Maximum  tem])eratui-e  between  100.5°  and  101.4° 90 

"        101.5°    "    102.4° 41 

"  "  "        102.5°    "    103.4° 10 

"  "  "        103.5°    "    104.4° 2 

Table  XXA^TIT. 

TABLK    or    DtKATlON    OF     J  K.^U'ERATURE. 

Cases. 

Fever  lasted  1  day 118 

"         "      2  days 2<> 

''         "      3     "    1 

"  "         5       ^'     1 

*  Fieber  in  der  Geburt.,  Winter.     Zeitscliiift  fiii'  <  Jchurlshiilfc  uiid  Gynaikologie, 
xxiii. 


ASEPSIS,    MORBIDITV,    AND   MORTALITY. 


247 


Table  XXIX. 

TABLE    OF    DAYS    OF    PUEKPEKIUM    ON    WHICH    RLSE    OF    TEMPERATURE    OCCURRED. 

Cases  with  temperature  on  one  day  only,  total  118.  Cases. 

Rise  of  temperature  occurred  on    1st  day  postpartum 31 


2d 
3d 
4th 
5th 
6th 
7th 
8th 
9th 
10th 
13th 


9 
15 
14 
17 

7 

14 

6 

2 
2 
1 


Cases  with  temperature  on  two  days,  total  20.  Cases. 

Kise  of  temperature  occurred  on  labor  day  and  1st  day  postpartum  . .     5 

u-        u        u        u      g^]^    cc  u 

"  1st  and  2d  davs 


1st 

'  5th  " 

2d 

'  3d  " 

2d 

'  8th  " 

3d 

'  4th  " 

3d 

'  5th  " 

3d 

'  8th  " 

5th 

'  6th  " 

5th 

'  7th  " 

Case  with  temj)erature  on  three  days,  total  1. 

Rises  of  temperature  occurred  on  labor  day,  1st  and  3d  days  postpartum. 

Cases  with  temperature  on  four  days,  total  3. 

Rises  of  temperature  occurred  on  1st,  2d,  3d,  4th  days  postpartum  in 
1  case. 

Rises  of  temperature  occurred  on  1st,  2d,  3d,  9th  days  postpartum  in 
1  case. 

Rises  of  temperature  occurred  on  3d,  4th,  5th,  6th  days  postpartum  in 
1  case. 

Case  wath  temperature  on  five  days,  total  1. 

Rises  of  temperature  occurred  on  2d,  3d,  4th,  5th,  6th  days  postpartum. 

Mortality  Statistics. 

The  total  mortality  among  the  10,233  cases  amounts  to  42  cases.  This 
is  a  total  mortality  percentage  of  0.41  per  cent.  Another  death  must  be 
added  to  this  list,  although  it  did  not  occur  in  one  of  the  10,233  deliveries. 


248 


REPORT   OF   THE   SOCIETY    OF  THE   LYING-IX   HOSPITAL. 


This  patient  died  oi  advanced  cardiac  disease  in  tlie  early  part  of  tlie  sev- 
enth month  of  ]>regnancv.  If  this  case  be  inchided  in  estimating  the  ratio, 
this  is  not  materially  altered,  bnt  is  sim])ly  increased  to  0.42  per  cent. 

If  tliese  deaths  are  tabulated  in  accordance  Avith  the  subdivision  of  the 
service  as  recorded  in  Table  I.,  page  23G,  the  following  table  results: 

TAm.E  XXX. 


No.  of 
Cases. 

No.  of  Deaths 
from  .Sepsis. 

Pr.Ct. 

No.  of  Deaths 

from 

all  Causes. 

Pr.Ct. 

1st  Period. 

Jan.,  "iM.)-Mar.,'92 
2d  I*eriod. 

Mar.,'92-Feb.,'95 
3d  Period. 

Feb.,'95-Apr.,'96 

1,454 

6,457* 

2,323 

8 
5 
2 

0.08^ 

14 

26 
3 

0.96^ 
0.40^ 
0 .  12,^ 

Totals 

10,234 

15 

0 .  14,'^ 

43 

()A2fc 

Tlie  mortality  percentages  in  each  successive  thousand  cases  is  shown  in 
the  following  table: 

Table  XXXI. 


No.  of 

No.  of 

Deaths 
from 

Per  Cent. 

Deaths 
from  all 

Per  Cent. 

Sepsis. 

Causes. 

First  Thousand 

6 

0 .  Ofc 

10 

1  .  Ofc 

Second      ''          

2 

0.2^ 

6 

0 .  ('4 

Third         "          

() 

<  1  .  (  K^ 

2 

0.2^ 

Fourth       "          

(_) 

n.();f 

5 

0.5fo 

Fifth          "          

(.» 

OAKi 

3 

0.3^ 

Si.xth         "          

3 

o.nfc 

8 

0.8^ 

Seventh    "         

0 

o.<»^ 

2 

0.2^ 

p:iglith      "         

2 

0.2^ 

3 

0.3^ 

Ninth        "         

1 

0.1^ 

1 

0.1^ 

Tenth        "          

(1 

O.i^'^c 

0 

0.0^ 

233  cases 

1 

0.4^ 

2 

0.8^ 

Antepartum  case .... 

0 

0.0^ 

1 



10,234  cases 

15 

0.14^ 

43 

0.42,^ 

These  percentages  are  subject  to  the  criticism  that  certain  of  our  cases 
souglit  otl)er  assistance  after  l)ecoming  ill,  and  may  have  died  subsequently 
from  the  effects  of  the  puerperal  inlVn-tion.  l-'ifty  |)atients  are  of  this  chiss, 
but  of  these  thirteen  were  sent  to  othci-  hos|>itals.  and  the  results  in  all  ai-e 

*  Th<'  ;iiitfi»:irtiiiii  dcilli  fi-om  lic;ir(  iliHoa.sf^  is  ;ii|(|cil  (o  lliis  series. 


d  pelvis Hfgli  t 


■"hysldno:! 


■  )l,.B'.A.t 


ASEPSIS,    MORBIDITY,    AND    MORTALITY.  251 

known  and  included  in  tliese  statistics.  Four  of  the  thirteen  died.  Thirty- 
seven  cases  sought  the  care  of  private  physicians.  The  hospital  has  traced 
three  of  these;  one  recovered  and  two  died,  and  are  included  in  our  records 
(C.  jN".  5, 799,  C.  N.  Y,538).  The  records  also  include  a  case  of  surgical 
kidney  following  cystitis  and  vesico-vaginal  fistula,  who  died  many  months 
after  her  discharge  from  the  service.  The  remaining  thirty -four  patients 
who  sought  other  medical  care  were  discharged  while  still  septic,  but  the 
severity  of  their  sepsis  varied  very  materially.  It  is  safe  to  infer  that  a 
large  majority  of  them  recovered.  The  following  table  gives  their  tem- 
peratures at  the  time  of  discharge: 

Table  XXXII. 

TEMPERATURE    AT    TIME    OF    DISCHARGE    OF    34    CASES    SEEKING-    OTHER    MEDICAL 


ATTENDANCE. 


Temperature  at  time  of  discharge  below  100.5° 


3 


"  "     "     "  "  between  100.5°  and  101.4" 5 

"  "     "     "  "  "       101.5°    "    102.4° 6 

"  "     "     "  "  "       102.5°    ''    103.4°....      11 

"  "     "     "  "  "       103.5°    "    104.4°....       5 

"  "     "     "  "         above  104.5° 4 

If  all  these  cases  are  included  as  deaths,  the  total  mortalit}^  would  be  77 
fatal  cases  in  10,233  cases,  or  0.75  per  cent.  Of  course  this  is  manifestly 
an  over-estimate;  nevertheless  even  this  figure  compares  favorably  with  the 
figures  of  other  obstetric  schools. 

Table  XXXIII. 

MORTALITY    PERCENTAGES    OF    VARIOUS    SCHOOLS. 

Cases.    Mortality. 

1.  University  Frauenklinik,  Berlin,  1888-95 8,528 1.93^ 

2.  Maison  d'Accouchements  Baudelocque,  Paris,  1890-95 .  10,861 ....  0.66^ 

3.  University  Obstetric  Clinic,  Prag,  1887-95 8,924 0.85^ 

4.  University  Frauenklinik,  Dorpat,  1888-93 889.  .. .  1.57^ 

5.  University  Frauenklinik  Poliklinik,  Dorpat 1,267. .  .  .2.2^ 

6.  University  Frauenklinik,  "NVurzburg 3,000. . .  .0.7^ 

1.  Ziir  puerperalen  Infection.  Koblanck,  Zeitsclirift  f .  Geburtshiilfe  nncl  Gynae- 
kologie,  1896. 

2.  Fonctionnement  de  la  Maison  d'Accouchements  Baudelocque.     Lepage,  1896. 

3.  Bericht  iiber  die  Morbiditats-verhaltnisse,  etc.  Pipek,  Monatschidft  fiir 
Geburtshiilfe  mid  Gyna?kologie,  1896. 

4.  5.  Berichte  und  Arbeiten.     O.  Kiistner,  1894. 

6.  Die  Verhiitung  des  Kindbettfiebers  in  den  geburtsbilflichen  Unterrichts- 
austalten.     Hofmeier,  Khniscbe  Vortrage,  1897. 

These  43  fatal  cases  have  been  arranged  in  the  order  of  their  occurrence, 
and  a  brief  statement  of  each  case  has  been  given  in  the  statistical  synopsis 
printed  above.  In  the  table  Xo.  XXXIY.  the  same  cases  are  arranged 
in  groups,  according  to  the  chief  cause  of  death. 


253 


REPORT   OF   THE    SOCIETY    OF   THE    EVIXC-IX    IIOsriTAL. 


The  l\»llo\ving  table  shows  the  cause  of  death  in  the  2S  fatal  cases  which 
died  from  other  causes  than  })uer})eral  infection,  and  the  mortality  per 
cent,  for  each  cause.     All  these  cases  wei-e  delivei-ed  l)y  the  Hospital. 

Table  XXXV. 


hilaiiiiisia   

Antepartum  ha'uiorrliage 

Postpartum  hiemorrhage 

Placenta  ]>rie\'ia j 

Eu]>ture  of  uterus ■ 

]*neumonia 

Phthisis 

Heart  disease i 

Suppression  of  urine  from  ether 

Erysipelas,  facial 

Surgical  kidney  following  vesico-vaginal| 
fistula,  1  year  postpartum ' 


11 
2 

2 

2 

4 
•> 

1 
1 
1 
1 


Xo.  Cases 
of  Com- 
plication 

Observed. 


]\Iortality 
Per  Cent. 


YS .  67  fc 


6.45^ 

12.5,'^ 

8.33$^ 
11.11^ 

100^ 


The  followino-  ta1)le  presents  a   further  analvsis  of  the  deaths  from 
septicaemia : 

Table  XXXVI. 


Delivered 

Midwife, 
etc. 

DELIVERED    BY    HoSPrj'AL. 

Operative 
Delivery. 

Spontaneous 
Birth. 

Total. 

First  tliousand 

Second      *'         

Si.xth         "        

Eighth      "        

Ninth       ''        

Eleventli  ''        

3 
1 

0 
0 
0 
0 

2 
0 
1 
1 
1 
1 

1 
1 
2 
1 
0 
0 

6 

2 
3 

2 

i 

1 

Totals 

4 

('. 

5 

15 

CONGENITAL   CYSTIC    KIDNEYS. 
By  Martha  Wollstein.  M.D. 


The  specimen  wns  removed  at  autopsy  from  a  female  infant  (C.  N.  132), 
born  at  term,  who  lived  twelve  hours.  Delivery  had  been  by  forceps  after 
a  labor  of  fifteen  hours;  the  position  was  right  occipito-posterior.  The 
child's  respirations  were  delaj^ed,  and  when  finally  established  they 
remained  irregular  and  shallow  until  death.  The  body  was  that  of  a  well- 
nourished  child,  with  a  marl^edly  prominent  abdomen  which  was  resistant 
to  the  touch  and  gave  no  evidence  of  fluctuation.  There  were  no  skin 
lesions  and  no  oedema.  Upon  opening  the  cranial  cavity,  the  pia  mater 
was  found  hyperaemic  over  the  entire  brain ;  there  was  no  extravasation  of 
blood,  and  the  brain  substance  was  normal.  In  the  lungs  there  were  large 
atelectatic  areas  in  both  lower  lobes,  the  anterior  border  of  both  upper 
lobes  being  emphysematous;  there  was  marked  congestion.  The  pleura, 
pericardium,  and  peritoneum  were  normal ;  the  heart  w^as  normal,  as  were 
the  pulmonary  artery  and  the  aorta.  The  liver,  spleen,  pancreas,  stomach, 
and  intestines  showed  no  change  from  the  normal;  nor  did  the  uterus, 
Fallopian  tubes,  ovaries,  and  vagina. 

When  the  intestines  were  removed,  two  large  masses  were  seen  to  fill 
the  entire  space  between  vertebral  column  and  lateral  body  walls.  These 
proved  to  be  the  kidneys,  each  measuring  twelve  centimetres  in  length,  by 
six  in  breadth,  and  four  in  thickness.  The  suprarenal  capsules  were  nor- 
mal in  size  and  position,  capping  the  upper  border  of  the  kidnej^s.  The 
ureters  were  traced  from  pelvis  to  bladder,  which  was  very  narrow,  small, 
and  empty.  It  was  cylindrical  in  shape,  showing  no  bulging  at  the 
fundus ;  the  trigonum  was  readil}^  found,  the  openings  of  both  ureters  and 
of  the  urethra  being  present,  but  very  small.  The  urachus  was  not  pervi- 
ous, and  the  umbilical  vessels  were  entireU^  normal.  The  kidneys,  supra- 
renal bodies,  bladder,  and  uterus  were  removed  e?i  masse,  and  w^eighed  375 
grammes. 

The  following  anatomical  description  applies  to  both  kidneys,  as  their 
condition  was  practically  identical.  They  had  a  distinctly%oggy  feel ;  on 
being  opened,  the  cut  surface  presented  a  peculiarly  cribriform  effect,  due  to 
the  dilatation  of  the  renal  tubules  everywhere  throughout  the  cortex  and 
medulla.  These  were  not  distinct,  the  one  from  the  other,  except  in  a  few 
places,  where  the  cortex  measured  one  centimetre  in  depth.     For  the  rest, 


254  REPORT    OF    THE   SOCIETY    OF   THE    LYING-IX    HOSPITAL. 

the  Itoiintlary  zone  between  cortex  and  medulla  was  entirely  lost.  The 
tuhnles  were  all  more  or  less  dilated,  aiul  a  very  few  cysts,  none  larger  than 
a  small  pea,  were  present  in  the  interior:  on  the  kidney  surface,  beneath  the 
capsule,  there  were  no  cysts  larger  than  one  to  three  millimetres  in  diam- 
eter. The  capsule  was  thickened  and  adherent.  The  appearance  of  the 
pelvis,  calices,  and  jiapilkv  was  very  striking.  The  Avail  of  the  pelvis  Avas 
smooth,  grayish-red  in  color,  and  very  much  thicker  than  the  correspond- 
ing ]>ortion  of  a  normal  kidney;  the  papilltx?  were  not  free,  as  is  usual,  in 
the  calices,  but  their  outline  as  ajnces  of  the  ]VIal[)ighian  pyramids  was  lost 
on  account  of  their  close  adlierence  to  the  thickened  Avail  of  the  kidney 
peh'is.  Of  the  nine  or  ten  pyi'amids  jiresent,  no  one  could  be  raised  out  of 
its  calix,  as  in  the  normal  kidney.  The  uj)})er  end  of  the  ureter  was  a  mere 
solid  cord,  two  millimetres  in  thickness;  at  a  point  about  two  or  three 
centimetres  below  the  pelvis,  the  ureter  became  somewhat  Avider,  and  Avas 
pervious  throughout  the  rest  of  its  course.  There  Avas  no  urine  in  either 
pelvis,  ureter,  or  bladder.  The  normal  fcetal  lobulation  of  a  kidney  at  l)irth 
Avas  entirely  lost;  a  condition  Avhicli  may  be  ex])lained  by  the  stretcliing  of 
the  organ,  due  to  the  distended  tubules  and  increased  stroma  l)etween  them. 
Figure  1  is  a  ])hotograph  of  the  gross  specimen,  and  shows  all  the  points 
enumerated  in  the  description. 

The  blood  sup})ly,  also  symmetrical,  varied  from  the  nonnal  in  that  tAVO 
renal  arteries  Avere  given  off  sej^arately  from  the  aorta  on  either  side,  about 
one  centimetre  apart;  the}'  branched  but  little  l)efore  entering  the  hilus. 
The  renal  veins  Avere  single,  emptying  into  the  inferior  A^ena  cava. 

Microscopical  examination  of  sections  cut  through  the  entire  depth  of  a 
Mal])ighian  pyramid  shoAV  an  extremely  interesting  and  unusual  condition. 
The  kidney  cajisule  is  sevei'al  times  thicker  than  normal,  and  is  comj)osed 
of  fibrous  connective  tissue  containing  comparatively  few  s])indle-shaped 
cells.  Two  things  are  strikingly  suggestive  in  the  kidney  substance — the 
large  amount  and  irregular  folding  of  e]nthelial  bands  and  masses,  and  the 
(juantity  of  (iljrous  connective  tissue,  rather  less  cellular  tlian  is  normal  in 
the  newly  b(ji-n.  Tlie  glomeruli  vary  much  in  siz(;,  some  being  smaller, 
others  lai'ger  than  normal,  that  is,  dilated.  They  contain  either  the  usual 
caj>illary  tuft,  or  a  mass  of  flattened  epithelial  cells,  oi'  tliey  are  emi)ty. 
They  are  present  throughout  the  cortex,  even  close  und(M*  the  capsule, 
avIk'I-c  some  renal  tulniles  can  be  seen  to  bend  and  coil,  others  to  illustrate 
the  lirst  entrance  of  the  capillary  tuft  into  their  blind  extremities.  None 
show  any  increase  of  connective  tissue  at  tlie  ex])ense  of  their  epithelial  or 
vascular  elements. 

There  are  very  few  renal  tubules  \\ho.s(!  epithelium  resembles  that  in  the 
normal  convoluted  tuljes,  and  still  less  which  can  be  classed  as  the  arms  of 
Ilenle's  loo]);  as  for  the  collecting  tul)ul('s.  tlici-e  ai-e  scarcely  any  which 
retain  their  noniial  nha,  slui])e,  and  lining.  The;  r<Mnainder  of  the  tubules 
in  the  specimen.s  are  cylinders  of  epithelial  cells,  sonn;  hollow,  some  solid, 
the  majority  having  no  distinct  membrana  propria.  ImiI  lying  directly  upon, 
or  rather  within,  the  conncc-tive  tissue  stroma,  to  which  they  are  rather 
loosely  a])plied. 


a 


r 


d" 


Fig.  1. — a,  riglit  kidney  ;  &,  left  kidney  ;  c,  suprarenal  capsules  ;  d,  bladder ;  e,  ureters  ;  /,  two 
renal  arteries  on  left  side  ;  g,  two  renal  arteries  on  riglit  side  ;  Ji,  renal  veins;  i,  vena  cava 
inferior  ;  /,  aorta  ;  Ic,  cysts  ;  I,  a  calyx  showing  thickened  wall  and  adlierent  papilla  ;  tn, 
uterus  ;  ?t,  vagina  ;  o,  narrowing  of  right  ureter  before  entering  pelvis  of  kidney  ;  p,  opening 
of  ureters  in  bladder. 


Fig.  2. — a,  folding  or  convoluting  of  the  tubes  ;  i,  large  cysts,  empty,  lining  gone  ;  c,  dilated 
glomerulus  ;  d,  normal  glomerulus  ;  e,  projections  into  lumen  of  tubules  ;  /,  glomerulus 
filled  with  epithelial  cells  ;  g,  collecting  tubes,  compressed  ;  h,  stroma. 


CONGENITAL    CYSTIC    KIDNEYS,  255 

Many  of  the  folded  strands  give  the  impression  of  l^eing  tuljules  forced 
to  double  on  themselves  for  lack  of  space  in  which  to  elongate  (see  Fio-. 
2,  a),  very  much  as  the  first  bend  is  formed  in  the  developing  kidney  tubules 
(Minot^),  when  the  capsule  acts  as  a  mechanical  obstacle  to  further  elonga- 
tion. Xauwerck  and  Ilufschmid '  call  attention  to  the  aj)parent  loosenino- 
of  the  e])ithclium  from  the  stroma,  and  point  out  the  fact  that  in  some  cases 
the  membrana  propria  is  thicker  than  normal;  in  others,  normal;  and  in 
others,  again,  has  entirely  disappeared.  By  far  the  greater  number  of 
tubules  in  this  specimen  are  minus  a  membrana  propria.  The  same  authors 
also  think  it  erroneous  to  attribute  this  loosened  condition  to  artificial 
causes,  such  as  shrinking  in  hardening,  etc. ;  it  is  certainly  too  universal 
and  too  constant  to  make  the  explanation  plausible,  or  at  least  acceptable,  as 
the  only  factor.  Furthermore,  were  the  epithelium  unfolded,  it  would  be 
found  to  be  much  too  long  a  band  to  fit  into  the  cavity  outlined  by  the 
stroma  immediately  outside.  That  there  are  coiled  and  recoiled  epithelial 
cylinders  is  evident,  and  that  this  condition  can  only  be  explained  by  an 
mmsual  proliferation  of  the  epithelium  in  excess  of  the  stroma,  is  also  plain. 
The  hollow  cylinders  are  lined  wath  a  single  row  of  beautifully  clear,  cubical 
cells,  whose  nuclei  stain  deeply ;  in  addition  to  these  there  are,  in  places, 
masses  of  clearer,  regular  polygonal  cells,  whose  nuclei  stain  less  deeply 
than  the  others.  They  resemble  exactly  the  nests  described  by  JSTauwerck 
and  Hufschmid,  and  fill  not  only  the  cylindrical  tubes,  but  the  globular 
glomeruli  as  well,  Karyokinetic  figures  can  be  demonstrated  in  the  epi- 
thelial cells  in  many  places. 

While  no  branched  papillary  outgrowths  were  found  in  any  one  of  the 
sections,  there  are  many  small  projections  of  the  cj^st  w^all  into  the  lumen, 
carrying  the  lining  epithelium  with  them.  There  are  also  numerous  exam- 
ples of  the  solid  branches  of  tubes  (Sprossenbildung)  pictured  by  JSTauwerck 
and  Hufschmid,^  some  of  which  show"  their  origin  distinctly.  jS'ear  the 
apex  of  a  Malpighian  pyramid  there  are  small  tubules,  w^hose  epithelial 
lining  is  a  row  of  low  columnar  cells,  resembling  a  compressed  and  inactive 
collecting  tube.  The  connective  tissue  in  this  region  is  greater  in  amount 
than  in  any  other  portion  of  the  kidney. 

The  wall  of  the  pelvis  is  greater  in  actual  depth  than  the  kidney  cap- 
sule; no  trace  of  a  lining  epithelium  remains,  and  the  papillarj^  apex  is 
united  to  the  pelvis  by  a  distinct  zone  of  round  cell  infiltration,  evidently 
inflammatory  in  origin.  The  blood  vessels  are  normal  as  to  the  structure 
of  their  walls,  and  are  neither  increased  nor  diminished  in  number.  Some 
of  the  tubules  and  cysts  contain  a  small  quantity  of  fine  granular  material, 
but  nowhere  any  colloid  substance. 

This  condition  of  the  pelvis  and  papillae  would  seem,  at  first,  to  illustrate 
to  a  nicety  the  theory  of  Yirchow  ^  as  to  the  formation  of  congenital  renal 
cysts — assuming  a  foetal  nephritis,  in  reality  a  pyelonephritis,  causing 
atresia  of  the  papillary  orifices  and  dilatation  of  the  renal  tubules  in  conse- 
quence of  their  compression  by  connective  tissue.  But  this  explanation 
clears  up  only  a  part  of  the  specimen,  leaving  the  epithelial  proliferation 
entirely  unelucidated.     Evidently,  instead  of  remaining  passive  and  becom- 


256  REPORT   OF   THE    SOCIETY    OF   TllK    LYIXG-IN    HOSPITAL. 

iiif  moiv  ami  more  riattenocl  as  the  tuluile  walls  beeame  ilistemled,  the  epi- 
thelimii  here  took  an  active  i)art  in  the  process,  giving  rise  to  a  comlition 
distinctly  adenomatous  in  character. 

Xaiiwerck  ami  lliit'schmid'  have  endeavored  to  prove  that  these  cystic 
kidnevs  are  to  be  classed  as  multilocular  adenocystomata,  explaining  the 
inflammatory  zone  between  the  kidney  and  pelvis  as  analogous  to  the 
romul  cell  infiltration  almost  constantly  found  at  the  periphery  of  epithelial 
tumors,  and  the  inflammatory  jirocess  in  the  pelvis  and  kidney  substance 
as  the  result,  not  the  cause,  of  the  cyst  formation  (pressure).  Arnold^ 
lias  shown  conclusively  that  a  in'imary  fa3tal  nephritis  does  occur,  but  the 
specimen  he  so  described  Avas  an  atrophic  kidney  with  microscopic  cysts 
only.  Viivhow  '  still  ui)lK)lds  his  original  theoiy,  and  emphatically  denies 
the  neo}»lasmic  origin  of  this  condition.  Chotinsky-"'  and  Brigidi  and 
Severi,*  though  conservative,  are  yet  inclined  toward  the  neoplasmic  view. 
and  Phillipson  '  considers  it  an  open  question  whether  the  proliferating 
epithelium  is  really  a  beginning  adenoma,  or  merely  a  compensatory 
hypertrophy.  Bland-Sutton^  takes  a  view  radically  different  from  any 
other  observer,  in  that  he  considers  cystic  kidneys,  both  foetal  and  adult,  as 
retention  cysts  of  persistent  Wolffian  (mesonephritic)  tubules,  and  thus 
classes  i^aroojihoron  cysts,  kidney  cysts,  and  innocent  cysts  of  the  testicle 
as  identical,  under  the  teratomata. 

Congenital  cystic  kidneys  have  been  recorded  which  were  so  large  as  to 
seriously  interfere  with  delivery  (Ortli)  ^^  or  to  cause  death  in  a  few  hours 
or  days,  as  in  the  present  case,  through  interference  with  respiration  by 
})ressure  u|>on  the  dia]ihragm.  On  the  other  hand,  the  condition  has 
remained  unsuspected  until  found  at  the  autopsy  in  adult  life.  It  is  quite 
common  to  find  other  malformations  coexisting.  As  reported  above,  the 
only  other  defect  ])resent  in  this  case  was  that  of  the  bladder,  and  how 
much  its  lack  of  size  (dilatation)  was  due  to  the  absence  of  the  mechanical 
factor  of  urine  distension  can  only  be  surmised. 

Two  exj)lanations  of  this  specimen  ai'e  ])ossil)le — either  there  was  a 
foital  pyelonephritis  accompanied  by  marked  e])ithelial  hyj^erti-ophy,  or 
else  a  foetal  cyst-adenoma  with  resulting  ])eripheral  inflammation.  The 
etiology  of  both  conditions  is  equally  dark.  Microscopic  study,  however, 
])oints  to  the  latter  as  the  more  tenable  hypothesis,  in  that  it  covers  all  the 
changes  noted.    Beyond  the  pajnllary  zone,  no  evidences  of  nephritis  exist. 


lhi!i.i<i(;i{Ai'Hv  TIeferrki)  to  IX  TJiK  Tkxt. 

1.  Nauwerck  and  Ilufschmifl:    rcbci-  das  Mnltilocnlare   Adenocystom 
der  Xiere.     Zeighn-'s  Beitriige,  bd.  xii. 

2.  Vircliow:  Uebej- liy(h'ops  Kciium  Cysticus  Congenitus.      Virchow's 
Archiv,  bd.  xlvi. 

'i.   Arnohl:    Cchf-r  Angcbf>renc  eniseitige  Nierenschrnmpl'ung  mit  Cys- 
tenbilduug.     Ziegler's  I>eitriige.  bd.  v. 

1.    Vircliow:    n<'rliin'r  klinis<  In- W'ochcnscliiif't.  lid.   xxix. 


CONGENITAL   CYSTIC   KIDNEYS.  257 

5.  Chotinsky:  Ueber  Cystenniere.     Inaug.  Dissert.,  1882. 
().  Brigidi  e  Severi:  Contributo  alia  patogenesi  clelle  cisti  renale.     Lo 
Sperimentale,  1880. 

7.  Phillipson:     Anatomische    IJntersucliungen     iiber    Nierencysten. 
Virchow's  Archiv,  bd.  iii. 

8.  Eland-Sutton:  The  Lancet,  1887. 

9.  Minot:  Human  Embryology. 

10.  Orth:  Lehrbuch  der  Speciellen  Pathologischen  Anatomic,  bd.  ii. 
17 


DEFORMED    PELVES, 

By  Austin  Flint,  Jr.,  M.D. 


The  statistics  on  which  this  article  is  based,  include  cases  already 
reported  in  a  pajier  entitled  "Observations  on  Pelvic  Deformities,"  read 
before  the  Xew  York  State  Medical  Association,  October  16,  1895.  The 
observations  then  made  were  mainly  for  the  purpose  of  determining  the 
frequency  with  Avhicli  pelvic  deformities  occurred ;  and  in  most  of  the  cases 
the  deformity  was  very  slight.  AVhen  the  Hospital  first  began  its  Avork, 
the  cases  were  in  some  res]")ects  imperfectly  recorded;  and,  as  many  instances 
of  minor  pelvic  deformity  were  undoubtedly  overlooked,  the  first  2,000 
histories  \vere  not  included  in  the  statistics,  and  the  figures  were  obtained 
in  0,000  consecutive  cases,  from  numbers  2,000  to  7,000  inclusive.  The 
observations  now  recorded  include  the  2,(H)0  ])reviously  omitted  and  the 
6,000  previously  v('])orte(l.  and  have  been  studied  with  reference  more  par- 
ticularly to  instances  in  wliich  deformity  is  well  marked.  In  addition  to 
this.  2,23;j  women  have  since  been  confined,  making  a  grand  total  of  10,233 
observations. 

Alth(High  the  object  in  rejiorting  these  cases  is  to  ascertain  the  results 
in  instances  of  mai'ked  deformity,  before  tabulating  and  analyzing  these, 
some  general  facts  in  regard  to  the  frequency  of  pelvic  deformity  in  all 
degrees  will  he  of  interest. 

It  is  necessary,  as  a  preliminary,  to  deline  what  is  meant  by  pelvic  deform- 
ity; and  to  do  this,  some  staiid;ird  of  size  must  be  ado})ted,  below  which 
pelves  may  l)e  called  ••  <l(roiiii('(l."  As  in  the  cases  reported  in  the  previ- 
ous article,  observations  liii\e  still  been  recoi'ded  accoi'ding  to  the  limits  of 
contraction  asdefin<'d  by  Litzmann  and  followed  by  the  majority  of  German 
writers,  in  which  all  cases  with  an  external  conjugate  of  eighteen  centi- 
metres or  less,  or  7.2  inches,  wen;  regarded  as  contracted;  but  these  statis- 
tics include;  onlv  cases  in  which  the  (•oniu'>at(?  measured  seven  inches  or 
less.  As  regards  the  nuc  conjugate,  Litzmann  inclndcd  as  contracted  all 
ca.ses  witli  a  measurement  of  I*^  centimeti'cs  or  ;!.s  inciies.  Disi-egarding, 
for  the  moment,  tlie  true  conjugate,  which  ninst  he  eslinialcd  from  the 
diagonal,  I  include  as  contracted  all  cases  with  a  diauonal  ineasnicnient  of 
4.i  ImcIh'S,  or  an  estimated  true  conju^'-ate  falling  sli^li11\    hch)w  tiiis  limit. 

Lnder  this  <l<'linition  of  pelvic  debjrmity,  in  a  total  of  1(),2.'>3  cases 
ohservetl,  contniction  was  j»resent  in  85f'>  cases,  oi-  x.'W  \n'A'  cent.  C'om])ar- 
ing  tliis  ])ercentuge  with  statistics  fi-om  Kuro])ean  sources,  it  will  he  noticed 


DEFORMED   PELVES.  259 

that  it  is  quite  markedly  less.  Thus:  Michaelis,  in  1,(»00  cases,  obtained  a 
percentage  of  13.1;  Litzmann,  14.9.  Winckel  believes  that  from  15  to  20 
per  cent,  of  women  liave  contracted  pelves;  Kaltenbach,  1-1  to  20; 
Schauta,  20.  The  report  from  Leopold's  clinics  for  1805  records  a  fre- 
quency of  24.3  per  cent.  It  has  already  been  stated  that  in  the  first  2,000 
cases  recorded  at  the  Hospital,  many  instances  of  minor  deformity,  accord- 
ing to  these  measurements,  were  omitted,  and  consequently  the  first  2,000 
were  disregarded.  In  the  previous  investigations,  the  histories  numbered 
from  4,000  to  0,000,  and  from  6,000  to  8,000,  showed  a  frequency  of  249 
and  251  respectivel}^,  or  12.4  and  12.9  per  cent,  respectively;  and  these 
percentages  are  correct  if  we  accept  the  definition  of  deformity  which  has 
been  described,  rather  than  the  percentage  of  8.36  in  10,233  cases.  A 
conclusion  that  may  be  drawn  is,  that  in  'New  York,  with  its  large  foreign 
population,  pelvic  deformities  occur  with  about  the  same  frequency  as  in 
Europe,  under  the  same  standard  of  measurements;  but,  as  will  be  shown 
later  on,  pelvic  deformity  in  which  the  obstruction  is  serious  enough  to  be 
noticed,  does  not  occur  with  the  same  frequency  here  as  abroad,  even  when 
compared  with  the  conservative  estimate  of  Winckel.  A  more  careful 
observation  and  a  larger  experience  in  the  treatment  of  these  cases  has  con- 
vinced me  that,  when  the  external  conjugate  diameter  is  the  only  one  which 
falls  below  the  standard,  contraction  does  not  necessarily  exist. 

As  a  part  of  the  routine  of  the  Hospital,  all  applicants  are  carefully 
examined  and  measured.  These  measurements  are  made  by  students,  under 
the  direct  supervision  of  the  resident  staff  of  the  Hospital  and  the  Board 
of  Assistant  Attending  Physicians.  To  insure  more  accurac}^  of  observa- 
tion, whenever  a  case  with  any  of  the  measurements  falling  below  the 
standard  is  found,  it  is  referred  for  diagnosis  to  the  assistant  attending 
physician  on  duty  in  the  examining-rooms  for  that  day.  In  other 
words,  external  measurements  are  no  longer  relied  upon,  but  internal  meas- 
urements, made  by  a  skilled  observer,  are  made  before  the  case  is  recorded 
as  one  of  deformity.  This  plan,  it  is  believed,  will  render  future  observa- 
tions much  more  accurate  and  uniform. 

Of  the  856  cases  of  deformity  recorded,  in  710  deformity  was  very 
slight,  or,  possibly,  did  not  exist.  The  external  conjugate  measured  seven 
inches  or  less  in  all,  but  labor  was  not  modified,  mth  the  exception,  per- 
haps, of  being  prolonged;  and  nearly  all  the  deliveries  Avere  spontaneous. 
In  this  number  there  were  14  forceps  deliveries  in  which  pehdc  deformity 
was  mentioned  in  the  account  of  the  operation.  In  none  of  these  cases, 
however,  was  the  diagnosis  of  contraction  borne  out  by  pelvic  mensura- 
tion, so  that  they  have  been  included  in  the  710  doubtful  cases,  and  not  in 
the  well-marked  cases. 

In  146  cases  deformity  Avas  marked.  This  means  a  frequency  in 
10,233  of  but  1.42  per  cent.,  Avhich  is  insignificant  as  compared  with  the 
ordinary  European  statistics,  and  very  moderate  as  compared  Avith  the  5 
per  cent,  of  serious  obstruction  estimated  by  Winckel. 

The  foUoAving  is  a  synopsis  of  the  146  instances  of  marked  pehdc 
deformity : 


2tiO 


REPORT   OF   THE   SOCIETY    OF   THE    LVINT.-IX    HOSPITAL. 


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262 


REPORT   OF   THE   SOCIETY    OF   THE   LVING-IN    HOSPITAL 


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DEFORMED    PELVES. 


263 


All  anal3'sis  of  this  Table  of  Deformed  Pelves  shows  the  following 
As  regards  etiology,  the  record  of  nativity  is  important: 


Russia 110 

United  States   0 

Austria 10 

Poland 7 

Germanv 5 


Ilnngaiy  . 
Ireland . . . 
Italy 

jS'ot  noted 


2 
1 
1 
1 
146 


A  glance  shows  that  the  great  majority  of  the  patients  were  Russians. 
There  are  one  hundred  and  thirty-six  foreign  born  and  but  nine  natives, 
disregarding  the  one  case  in  which  the  nativity  was  not  noted.  This  great 
preponderance  of  foreign  over  native  women  exists  not  only  in  cases  of  pel- 
^ac  deformit}",  but  also  in  the  general  statistics,  and  very  nearly  in  tlie  same 
proportion. 

Thus,  in  a  total  of  10,233  cases,  the  nativity  in  163  cases  was  not  noted, 
910  were  native,  and  9,180  were  foreign  born. 


GENERAL    STATISTICS. 

]S"ative,  910  ;    foreign,   9,180. 
projDortion  of  1  to  10.08. 


A 


DEFORMED    PELVES. 

Native,  9  ;  foreign,  136. 
portion  of  1  to  15.11. 


A  pro- 


About  one-third  less  in  the  deformed  pelvis  cases  than  in  the  general 
statistics.  The  majority  of  all  the  foreign-born  patients  were  also  Rus- 
sians, 6,885  in  a  total  of  9,180. 

It  is  still  worthv  of  note  that  only  nine  cases  of  marked  pelvic  deformity 
were  observed  among  nine  hundred  and  ten  Avomen  of  American  birth. 

As  regards  the  age  of  the  patients,  the  majority  were  between  twenty 
and  twenty-five. 

Age  of  Patients. 


Cases. 

Under  20 7 

Between  20  and  25 67 

"        25    "    30 U 

"        30    ''    35 20 

The  para  is  recorded  as  follows: 

Paka 
Cases. 
38 


Cases. 


Between  35  and  40 
Xot  noted 


Total 146 


I 

II 

III 

lY 

Y 

YI 


24 

22 
24 
17 
10 


YII . . . . , 

YIII 

IX 

X 

Xot  noted 


Cases. 

5 
2 
2 
1 
1 


Total 146 


Even  a  marked  pelvic  deformity  does  not  seem  to  act  as  a  bar  to  bring- 
ing up  quite  a  large  famil}^  of  children.  One  hundred  and  eight  of  the 
women  were  multipar£e. 


264 


REPORT   OF   THE   SOCIETY    OF   THE    LYING-IN    HOSPITAL. 


Month  of  Gestation 
Cases. 


7^  months  in 
8 


Cases. 

9  to  10  months  in 143 

Xot  noted 1 


It  is  interesting  to  note  that  the  pelvic  deformity  had  api)arently  no 
effect  whatever,  as  far  as  the  pregnancy  was  concerned.  Nearly  all  were 
deliveretl  at  full  tei'm. 

A'akiety  of  Defokmity. 


Cases. 

Simple  flattened  pelvis 79 

Justo-minor  ])elvis 39 

Flat,  generally  contracted,  pelvis  19 

Naegele's  oblique  pelvis 3 

Contracted  outlet 2 

JSpondylolisthetic 1 


Cases. 

Scolio-rachitic 1 

Male    type    (transversely    con- 
tracted outlet ) 1 

Karrow  pubic  arch 1 

Total 140 


The  simple  flattened  type  predominated,  occurring  in  more  than  one- 
half  of  the  cases.  It  is  unfortunate  that  the  histories  are  not  sufficiently 
clear  to  enable  me  to  separate  the  rachitic  and  non-rachitic  varieties  with 
any  degree  of  accuracy. 

The  degree  of  deformity  is  perhaps  of  more  importance  than  the  type, 
and  a  table  has  been  made  as  follows : 


Conjugata  Yeea. 


Inches. 

^ 

3^ 

3i  to  3f 

H 

H 

3  to  3]^ 2 


Cases. 

.     79 
.     24 


20 
9 


Inches. 
3t  .  .  .  . 
3f  .  .  .  . 


Cases. 
1 
1 
3 


Not  noted 12 


Total 14(3 


I  have  ])ut  down  the  conjugata  vera  exactly  as  it  was  recorded  in  the 
history,  in  each  case.  In  scjme  instances  no  conjugata  vera  was  I'ecorded 
when  the  diagonal  measured  4-^  inches,  and  in  such  cases  I  have  estimated 
tin;  vera  as  3|,  irres])ective  of  the  height  of  the  syui])liysis  or  tlie  inclina- 
tion of  the  pelvis.     For  this  reason.  3^  make  up  about  half  of  the  cases. 

Of  the  twelve  cases  in  which  no  conjugata  vera  is  recorded,  two  were 
cases  of  Nacgeh;  oblicpie  jKilvis  ;  one  was  a  case  of  conti'acted  outlet  (3^ 
inciies  l*etween  the  ischial  spines);  two  were  cases  of  "  rigid  coccyx:  "  one 
was  a  case  of  "  narrow  ]nd)ic  arch  ;  "  one  was  a  consultation  case  in  wliich 
no  measurements  were  taken;  and  seven  were  cases  in  uliicli,  Avhile  deform- 
ity was  present,  as  sliown  by  the  nieeli;inisni  of  the  labor,  no  conjugate  Avas 
re<;or(le<l.  In  these  last  cases,  the  fault  was  in  recoriling  tin?  history;  so 
that,  although  impossible  to  classify,  llxy  must  be  inehaled  as  "  defoi-med." 


DEFORMED   PELVES. 


265 


In  the  one  hundred  and  forty-six  cases  in  the  table,  the  following- 
operations  were  performed : 

Forceps 24 

Attempted  forceps  (followed  by  version) 6 

Podalic  version  (G  cases  after  forceps) 33 

Cephalic  version , 1 

S3nn])hysiotomy 6 

Extraction  of  breech  (1  case  twins) 6 


Accouchement  force 

Csesarean  section 

Manual  extraction  of  head 

Induced  labor 

Conversion  brow  to  vertex 

Craniotomy  on  after-coming  head 


Total 86 

These  eighty-six  operations  were  done  on  sixty-seven  cases.  In  the 
remaining  seventy-nine  delivery  was  spontaneous.  In  none  of  the  sponta- 
neous cases  was  the  conjugate  less  than  3^  inches,  although  the  conjugate 
was  so  recorded  in  seven  instances. 

Complications. 

Cases. 

Fracture,  child's  skull  (forceps) 1 

"  Depression,"  child's  skull  (version) 3 

Fracture  humerus 3 

Prolapsed  cord 7 

Albuminuria 5 

Lacerated  perineum  (requiring  suture) 8 

"         cervix  "  "        4 

Extension  after-coming  head 1 

Uraemia 1 

An  analysis  of  position  and  presentation  shows  the  following: 


Position.  Cases. 

L.  O.  A 89 

E.  O.  A 26 

L.  O.  P 7 

E.  O.  P 8 

L.  Sac.  A 3 

E'.    "     P 2 

E.    ''     A 1 

L.  Scap.  A 1 

E.     "      A 1 

L.  M.  P 1 

l^ot  noted 7 

Total 146 


Presentation.           Cases. 
Vertex 130 


Shoulder  . 
Brow  .... 
Left  ear  .  . 

Face 

Breech  .  . . 
Not  noted 


Total 146 


266  REPOKT   OF  THE  SOCIETY   OF   THE   LYING-IX   HOSPITAL. 

The  general  result  as  regards  mortality  in  the  one  hundred  and  forty- 
six  cases  is  as  follows: 

Maternal  deaths 3 

Children  still-born 19 

who  subsequently  died 7 

Of  the  three  maternal  deaths,  one  was  in  a  case  of  albuminuria,  death 
occurring  the  first  day  i)()sti)ariuni,  with  fever.  The  second  death  occurred 
three  weeks  j)osti)artum.  from  sepsis,  and  the  third  fatal  result  was  due  to 
uraMuia  also,  al)()Ut  three  weeks  after  the  delivery.  This  case  was  a  for- 
ceps delivery  indicated  by  a  sharjtly  curved  and  rigid  coccyx,  and  is  included 
among  the  twelve  cases  of  irregularly  deformed  pelves. 

The  results  in  the  various  degrees  of  contraction  are  of  such  impor- 
tance, that  I  repeat  the  table  of  measurements,  dividing  the  cases  into  four 
classes : 

Cases. 

Pelves  measuring  3f  inches  or  more 79 

3^      "      and  less  than  3| 27 

"  '•  31      "  ''  3i 23 

3        ''  ''  SI 5 

Total 134 

These,  with  the  twelve  cases  of  irregular  contraction,  make  a  total  of 

Taking  up  the  first  seventy-nine  cases,  in  which  the  conjugata  vera 
measured  3;|  inches  or  more: 

Cases. 
Delivery  was  spontaneous  in 53 

by  forceps  in 16 

"         by  a  manual  extraction  of  a  breech  presentation 

in  4 

"         was  ])remature  in 1 

'*         by  version  for  a  shoulder  presentation  in 1 

"                  "        after  symphysiotom}^  in 1 

"                  "         for  prolapse  of  the  cord  in 3 

Total 79 

Rt^^sultf*. — Among  these  cases  there  was  one  maternal  death,  a  forceps 
delivery  in  a  case  of  all)uniinuria  and  fever,  death  occurring  on  the  first 
day  prjstpartum. 

There  were  also  ten  fo-tal  deaths,  as  follows: 

Cases. 
In  a  sponUineous  delivery  (no  cause  assigned) 1 

After  a  forcej)s  delivery 5 

"  version  delivery  and  |»rola|»s('tl  cord 2 

**  premature  delivery 1 

**  pn)long('d  labor  aud  cxf  rcuic  moulding  of  tlic  head  1 

ToImI K) 


DEFORMED   PELVES.  267 

CoNJUGATA  Vera  Measuring  3^  Inches  and  Less  than  3f. 

The  twenty-seven  cases  in  this  class  terminated  as  follows: 

Cases. 

Delivery  was  spontaneous 11 

"  "by  version 13 

"  "     "  forceps 2 

"  "     "a  manual  extraction  of  breech 1 

Total 27 

The  forceps  cases  were  uncomplicated. 

In  eleven  of  the  cases  delivered  by  version,  the  operation  was  com- 
plicated as  follows : 

Cases. 
By  previous  attempts  to  deliver  with  forceps,  one  of  these 

also  having  a  prolapsed  cord 4: 

By  a  symphysiotomy 1 

By  a  prolapsed  cord 2 

By  an  ear  presentation 1 

By  so-called  ' '  accouchement  force  " 2 

By  extension  of  the  head  at  the  brim 1 

Total 11 

It  is  interesting  to  note  that  in  one  of  these  version  cases  a  living  child 
was  extracted  through  a  pelvis  which  had  required  the  operation  of  sjan- 
physiotomy  at  a  previous  confinement. 

JResuUs. — In  this  grou])  there  likewise  occurred  a  maternal  death,  the 
woman  dying  of  sepsis  three  weeks  postpartum.  The  conjugate  measured 
3-|  inches,  and  version  was  performed  after  a  manual  dilatation  of  the 
cervix. 

There  were  seven  still  births,  and  one  subsequent  death  of  the  child. 

1  still  birth  was  after  a  forceps  delivery. 

2  after  version  operations  that  were  uncomplicated. 

1  after  a  version,  attempted  forceps,  and  prolapsed  cord. 
1     "  "         and  prolapsed  cord. 

1     "  "         in  which  the  mother  also  died. 

1     "  "         in  which  the  extended  head  was  arrested  at  the 

brim. 

The  subsequent  death  of  the  child  followed  a  delivery  by  version  after 
forceps  had  failed. 

Of  these  cases,  which  were  not  what  might  be  called  very  highly  con- 
tracted, eleven  were  spontaneous  deliveries.  In  the  sixteen  operative  de- 
liveries, delivery  by  forceps  was  attempted  six  times  and  was  successful  in 
but  tAvo  instances;  and  in  the  fourteen  remaining  cases,  the  child  was 
extracted  bv  the  feet. 


268  REPORT   OF   THE   SOCIETY   OF   THE    LYTNO-IX    HOSPITAL. 

This  seems  to  prove  tlmt  a  head  can  be  tlragged  through  a  contracted 
brim  more  successfully  when  it  is  made  to  engage  by  tlie  smaller  "  wedge- 
sha])eil "  base  than  by  the  more  rounded  vault.  AVhether  the  ultimate 
result  for  the  child  is  as  favorable,  taking  into  account  the  probable  delay 
in  the  extraction  of  an  arter-coming  head,  is  (juostionable. 

CoNJCGATA  Vera  Measuring  H  Inches  and  Less  than  3^. 

There  were  twenty -three  cases  iii  this  class. 

Cases. 

Delivery  was  spontaneous 1<> 

''  "    by  forceps 1 

"  *'  ''         following  a  cephalic  version ...  .  1 

'<  *•     "a  manual  extraction  of  the  breech  after 

an  induced  lalxu- 1 

"  "     "    version 10 

Total 23 

It  will  l)e  seen  that  in  this  series  nearly  one-half  were  s])ontaneously 
delivered,  although  the  contraction  was  marked.  In  the  remainder,  deliv- 
ery bv  forceps  was  attempted  in  tliree  and  was  successful  in  but  two 
instances.  In  eleven  cases  the  child  was  extracted  by  the  feet.  Of  the 
ten  cases  in  which  podalic  version  Avas  done,  symphysiotomy  was  neces- 
sarv  in  two  instances,  and  the  choice  of  version,  rather  than  of  forceps, 
indicated  in  two  others  by  ])rolapse  of  the  coi'd.  AVhat  has  been  said  of 
the  advantages  of  version  over  force]is  in  slightly  larger  ])elves,  seems  to 
be  more  markedly  demonstrated  in  tliis  series,  in  which  the  contraction  is 
more  ))ronounce(l. 

Jii.'»nlt.s. — There  wei'c  no  maternal  deaths  and  live  still  birtlis — one  in  the 

forceps  case,  another  in  the  induced  labor  case  in   wliicli  the  l)i'eech  i)]'c- 

sented,  and  three  folhjwed  delivery  by  version.      Of  the  later  three,  one 

was  macerated,  and  two  had  a  depression  of  the  skull.     One  of  these  had 

been  sul>jected  to  an  ineffectual  effort  to  deliver  by  high  forceps,  and  the 

fracture  in  the  otlicr  case  was  due  to  efforts  to  extract  the  after-coming 

head. 

Co.NjrGAT.v  Vera  Measuring  3  Inches  and  Less  than  3^. 

There  were  l)iit  live  sucli  cases,  and  the  delivery  was  by — 

Case. 

Forceps 1 

Sym])hysiotoniy  aii<l  vci-sioii   1 

Version 1 

Cicsarean  socli(»n  1 

A^'ersion  fulloucd  l»\-  a  craniotoinN'  on  t  ln'  al'tci'-coniing  Ik 'ad  1 

litnultM. — No  inat<!rnal  deaths. 

Two  fo'tal  deaths  in  the  vei'sion  cases,  in  one  of  which  there  Avas  a 
depression  of  the  elilNrs  skull,  resulting  Ironi  the  ell'oi'ts  to  extract  through 
a  conjugate  of  but  three  inches.  In  the  second,  extraction  was  performed 
with  great  ditiiculty  aftei-  pnfoi-atin^'-  and  ciiishin;:'  tlu!  aftei'-coining  head. 


DEFORMED   PELVES.  269 

All  of  tlio  fatal  cases,  both  foetal  and  maternal,  occurred  in  these  cases 
which  have  been  described  in  detail,  with  the  exception  of  the  delivery  of 
one  still-born  child  by  forceps,  in  consultation  in  a  case  in  Avhich  no  meas- 
urements were  obtained. 

An  analysis  of  these  cases  brings  up  several  points  of  interest  which 
might  be  discussed  at  length. 

First.  — The  question  of  frequency,  both  in  regard  to  cases  of  moderate 
deformit}^  and  cases  in  Avhich  deformity  is  well  marked. 

Second. — The  influence  of  the  deformity  on  labor  in  the  various  degrees 
of  contraction. 

Third. — The  best  means  of  extraction  in  the  various  degrees,  and  the 
results. 

Under  the  tirst  heading,  regarding  the  frequency,  but  little  remains  to 
be  added  to  a  plain  statement  of  figures.  Deformity  of  all  degrees  may 
be  met  with  in  practice,  in  about  12^  per  cent,  of  all  cases,  according  to 
the  standard  of  measurements  used  in  foreign  statistics.  This  result  was 
obtained,  not  in  the  whole  number  of  cases  observed,  but  in  four  thousand 
consecutive  cases.  Deformity  serious  enough  to  materially  influence  labor 
and  demand  active  operative  interference  may  be  met  with  in  about  1^ 
per  cent,  of  all  cases. 

In  comparison  with  foreign  statistics,  deformity  marked  enough  to 
form  a  serious  obstacle  to  delivery  occurs  in  about  one-third  as  many 
instances,  and  slight  deformity  with  about  the  same  frequency. 

Statistics  from  the  Boston  Lying-in  Hospital  give  a  frequency  of  two 
j)er  cent,  in  native  women  and  six  per  cent,  in  foreign  women  (Reynolds). 

Under  the  second  heading,  the  influence  of  the  various  degrees  of  con- 
traction on  labor,  it  may  be  said  that  a  large  proportion  are  delivered 
spontaneously,  even  when  the  obstruction  is  apparently  formidable.  In 
cases  that  demand  interference,  the  choice  of  operation  depends  more  on 
the  size  of  the  child's  head,  the  character  of  the  labor  pains,  and  malpres- 
entations  or  positions,  than  on  the  degree  of  contraction  itself.  This  is 
illustrated  by  abundant  facts  in  the  tables.  As  examples  may  be  mentioned 
the  case  requiring  symphysiotomy,  with  a  conjugate  of  3f  inches,  and  the 
spontaneous  deliveries  in  cases  of  3^  inches.  When  the  contraction  is 
marked,  and  delivery  is  not  spontaneous,  the  operations  that  are  required 
are,  as  a  rule,  the  more  difficult  major  operations. 

Third. — The  best  means  of  extraction  in  the  various  degrees. 

It  is  difficult  to  make  rules  to  govern  the  treatment,  except  when  the 
deformity  is  very  marked — under  3^  inches.  With  a  conjugate  of  about  that 
diameter,  spontaneous  delivery  is  possible  in  a  larger  proportion  of  cases 
than  is  ordinarily  supposed. 

When  the  disproportion  between  the  size  of  the  head  and  the  size  of 
the  canal  is  not  marked  enough  to  prevent  extraction  by  the  natural  pas- 
sages, the  choice  lies  between  forceps  and  version. 

Delivery  by  forceps  has  been  successful  mainly  in  the  cases  where  a 
waiting  plan  has  been  adopted,  the  head  has  moulded  and  delivery  by 
forceps  has  failed  when  attempted  earlier. 


270 


REPORT   OF   THE   SOCIETY    OF   THE    LYIX(;-1X    HOSPITAL. 


The  results  for  the  mother  in  either  operation  should  be  the  same,  if  it 
is  done  or  attem})ted  bv  one  wlio  is  familiar  \\ith  its  dangers  and  is  ordi- 
narily skilful. 

In  the  whole  series  of  one  hundred  and  forty-six  cases,  forceps  were 
applie<l  twenty-four  times,  and  ])odalic  version  was  pei'formed  thirty-three 
times. 

The  tiiirty -three  version  operations  include  six  cases  in  which  forceps 
had  been  attempted  and  had  failed.  The  results  of  these  operations  can  be 
seen  by  comparing  forceps  with  version  in  parallel  columns. 


Forceps. 

Version. 

clConJ. 
SS  Vera. 

Mother. 

ChUd. 

Remarks. 

1 

Conj. 
Vera. 

Mother. 

Child. 

Remarks. 

1      ? 

Recov'd. 

Rec'ov'd. 

Fractured  child's  skull. 

3i 

Kecov'd . 

Recov'd. 

Prolapsed  cord  ;  lacer- 

2i   3» 

" 

Ceuhiilic     vei-siou     lor 
snoulder  pres. 

ated  ]>erineum. 

2 

3} 

" 

" 

After  syiiH)liysi(itomy. 

3 

3-3i 

" 

" 

Liicei-ated  i>erineura. 

3 

3i 

" 

" 

After  s'ymphy.siotuiuy  ; 

4 

:H 

" 

" 

perinoorrliapliy. 

3 

" 

" 

Allnimiiuiria 

4 

3 

" 

" 

After  synipliysiotumy ; 

6 

3» 

Did  .... 

" 

.Vlbuniiiiuria  and  fever. 

fractured  humerus. 

7 

3J 

Recov'd. 

'• 

o 

3i 

" 

Died    . . . 

After  forceps. 

8 

3f 

" 

" 

Trachelorrhaphy. 

G 

3M 

" 

Kecov'd . 

Prolapsed  cord. 

S* 

3t 

•' 

" 

7 

3} 

" 

111 

? 

" 

Still 

Consultation  case. 

8 

3J 

" 

" 

After  symi)hysiotomy. 

n 

■n 

" 

Died  .... 

Occiput  posterior. 

9 

3* 

" 

" 

*'                 " 

lu' 

■H 

Kecov'd . 

10 

3i 

" 

" 

2  yeare  after  symphysi- 

i:j 

■H 

Still..  .. 

" 

otomy. 

14 

3| 

Died  .... 

11 

3} 

" 

" 

ShoiiMcr  prcscMtatidii. 

15 

31 

Kecov'd. 

12 

3i 

" 

" 

Face  prcscntaiidii. 

16 

3» 

" 

.«                k>               kk 

13 

? 

" 

" 

Contracted  oiillet;  sym- 

i: 

3» 

Still 1 

physiotomy;  brow;  pe- 

18 

31 

" 

Kecov'd . 

rineorrh.;    attempted 

1« 

31 

" 

forceps. 

a> 

31 

" 

21 

3» 

Manual  dilatation    of 
cervi.\. 

14 
115 

3i 
3i 

" 

4k 

Perineorrhaphy. 
Trachelorr.;  perin. 

22     .Tf 

Still 

Occiput  posterior;  man- 
ual dilatation. 

ir 

3 

;: 

Died  .... 

Depression  child's  skull. 

B     3» 

** 

"    

Occiput  posterior. 

IS 

3} 

" 

Recov'd . 

Attempted  forceps. 

24 

31 

" 

Recov'd . 

19 

■ii 

" 

" 

*'               " 

20 

4 

Died  .... 

Still 

Fever. 

21 

3} 

Recov'd . 



Prolajisod      oonl  ;      at- 
tem|it('(l  forceps. 

22 

3i 

AtteniptiMl  forecps  ;  de- 
pi'cssion  cliild's  skull. 

23 

31 

** 

"    .... 

Prolaiiseil  cord. 

24 

3 

Ci-aniotomy,  after-com- 
ing' lieiiii. 

25 

3* 

" 

**    

Depression  child's.skidl. 
Child  maeerated. 

2H 

•a 

*' 

"    

27 

31 

" 

Liviiiff  . . 

Prolapsed  cord. 

28 

3i 

" 

Still  ..... 

E.vtended  after-coming 
head. 

29 

31 

" 



Prolapsed    cord  ;    frac- 
turol  humerus. 

30 

3* 

" 

"    

Prolapsed  cord 

31 

3^ 

" 

"    

32 

3» 

" 

•' 

33 

Died  .... 

Living-  .. 

Urteniia;    rifid  coccy.x. 

The  results  shown  by  the  preeciding  tabic  are  as  follows: 

TliHM;  deatlis  of  mothers. 

Twenty-one  deaths  of  children. 

The  cau.ses  of  tlic^  maternal  <leat]is  need  not  be  re])eated,  as  tliey  have 
alre^idy  Imm-u  descrihed  in  detail;  and,  with  the  ('xi'e])tion  of  one,  they 
could  not  have  been  caused  by  the  operation. 

Of  the  twfnty-one  deaths  of  cliildrcii,  seven  were  after  forceps  and 
fourti^en  after  version  operations. 

It  JH  necessary  to  go  into  details  in  order  t<.  explain  sncli  an  apparent 
sujieriority  in  the  results  al'tei-  forceps.     The   iiHiviised    iimidiei'  of  deaths 


DEFORMED    PELVES.  271 

iri  the  version  column  may  be  partially  explained  by  the  fact  that  there 
were  nearly  one-third  more  version  operations.  Again,  six  of  the  versions 
were  undertaken  after  forceps  had  been  tried  and  had  failed,  and  three  of 
the  deaths  were  of  these  six.  In  one  of  these,  death  was  distinctly  due  to 
forceps,  it  having  been  found  that  the  cord  had  prolapsed  and  was  pinched 
between  the  head  and  forceps  blade. 

It  is  significant,  also,  that  deformity  was  more  marked  in  the  version 
cases  than  in  the  forceps  cases.  In  the  former,  twenty-six  had  a  conjugate 
below  3^  inches,  Avhile  only  five  such  cases  occurred  in  the  forceps  deliv- 
eries. In  other  words,  nearly  all  the  forceps  deliveries  were  in  moderately 
deformed  pelves  as  compared  with  the  cases  of  version  deliveries. 

If  the  column  of  ' '  Remarks  ' '  be  examined  for  a  probable  explanation 
of  a  still  birth,  in  each  instance  it  will  be  found  that  there  were  no  com- 
plications in  the  forceps  cases  other  than  occiput  posterior  positions,  which 
were  present  in  five  of  the  seven.  Of  the  still  births  after  version,  death 
Avas  due  to  causes  other  than  the  version,  as  follows : 

1.  Depression  of  child's  skull  in  three  cases,  with  a  conjugate  of  3 
inches  in  one  case,  and  3^  in  another  (complicated  with  forceps),  and  3^  in 
a  third. 

2.  Prolapse  of  cord  in  three  cases. 

3.  Arrest  of  the  head  necessitating  a  craniotomy  in  a  case  in  which  the 
pelvis  measured  but  three  inches. 

4.  A  macerated  child  in  still  another  case. 

Taking  into  account  the  accidental  complications,  and  the  more  pro- 
nounced pelvic  deformity,  the  results  as  regards  the  child  are  more  favor- 
able after  version  than  after  forceps. 

Given  a  case  of  deformed  pelvis  in  which  the  disproportion  is  not  suffi- 
ciently great  to  preclude  the  possibility  of  extracting  a  living  child,  in  the 
majority  of  instances  version  is  the  better  operation  from  all  points  of  view. 

I  do  not  think  that  it  would  be  occupying  an  extreme  position  to  say 
that  forceps  should  never  be  applied  to  the  head  when  it  is  movable  above 
the  brim,  in  cases  of  pelvic  deformit}^.  There  is  only  one  condition  that 
might  be  an  exception  to  this  rule.  When  the  patient  is  seen  after  the 
mehibranes  have  ruptured,  the  amniotic  fluid  drained  away,  and  the  uterus 
is  tightly  contracted  about  the  child,  cautious  attempts  may  be  made  to 
engage  the  head  with  forceps.  Failing  in  this,  delivery  can  only  be 
accomplished  by  a  difficult  version  or  a  more  radical  operation.  Such  a 
condition  can  only  occur  Avhen  the  disj^roportion  is  great. 

Such  varied  conditions  may  be  present  in  any  given  case,  that  no  rule 
can  be  made  that  is  absolute.  For  the  general  practitioner,  version  is 
safer,  is  easier,  and  gives  better  results  in  cases  of  pelvic  deformity  than 
forceps.  For  the  practitioner  skilled  in  midwifery,  the  same  rule  will  hold 
good  in  the  majority  of  cases.  Face  to  face  with  other  complications,  he 
should  be  capable  of  making  rules  for  his  own  guidance. 

Special  training  and  experience  will  often  enable  an  operator  to  over- 
come difficulties  insurmountable  to  another,  whether  the  operation  be  for- 
ceps or  version. 


CiESAREAX  SECTION  IN  A  EACIIITIC   DWAKF. 
By  James  W.  Markoe,  M.D. 

Previous  History. 

C.  X.  o.oOC).— The  patient,  a  primipara,  thirty-four  years  of  age,  Avas 
born  in  Pohind,  and  came  to  this  country  but  three  months  ago.  She  states 
tliat  when  nine  months  old  she  first  began  to  walk,  and  was  perfectly  well 
and  strong  until  reaching  the  age  of  two  years,  when  she  was  badly 
scalded  upon  the  left  arm  and  side.  From  the  description  of  what  fol- 
lowed, rickets  evidently  developed,  she  being  unable  to  walk  again  until 
her  seventh  year.  Since  that  time,  she  has  always  been  well,  except  for 
deformitv.      ^Menstruation  began  at  fourteen,  and  has  always  been  normal 

in  character  and  duration. 

Examination. 

Dr.  T.  Ilalsted  Myers  examined  the  patient  and  reported  as  follows: 
''A  rachitic  dwarf,  fifty  inches  in  height,  with  marked  rotary  lateral 
curvature  of  tlie  dorso-lumbar  spine.  The  vertebrge  from  the  ninth  dorsal 
to  the  fifth  lumbar  were  markedly  deformed.  The  lateral  deviation 
amounted  to  one  inch,  and  this  brought  the  ribs  on  the  right  side  against 
the  iliac  crest,  while  on  the  left  they  were  two  inches  above  it.  The  pos- 
terior rotation  of  the  lower  ribs  as  the  patient  stooped  forward  was  two 
and  a  half  inches.  The  lumbar  spine  showed  less  than  the  normal  lordosis, 
The  sacrum  seemed  very  flat,  and  its  anterior  concavity  less  than  normal. 
The  inclination  of  the  ])elvis  to  the  horizontal  plane  was  50^  degrees. 

Measurements  of  l:*EL^'ls. 

Inches.  Cent. 

Anterior  superior  s])ines 9^  24 

Crests 10  26 

External  ()l)liques  (both) 8  20| 

con  ju^'-atc of  l-J-J 

Diagonal  c<jnjiigato 4  10 

True  conjugate 8  7^ 

Height  of  symphysis 2  5 

"  The  racliitis  had  jjrrulnccd  a  ps('U(lo-))aralysis  lor  a  longtime,  therefore 
the  lower  limbs  were  but  little  deCormed.  IJotli  Icuioi-a,  showed  some  ante- 
rior curvature,  and  there  was  slight  knock  knee  and  Hat  foot  on  the  left 
side.     The  up|x;r  extremities  were  well  fonned.  buldwarfed." 


Case  of  CissAREAN  Section. 
C.  N.  5,506. 


Case  of  Cesarean  Section. 
C.  N.  5,506. 


CESAREAN   SECTION    IN    A    RACHITIC    DWARF.  273 

After  consultation  Avitli  the  other  members  of  the  attending  staff, 
Cjesarean  section  was  decided  upon  as  the  only  chance  for  the  mother  and 
child.  As  she  was  in  the  ninth  month  of  pregnancy,  nothing  was  to  be 
gained  b}^  operating  immediately.  AVhen  labor  should  commence  was 
chosen  as  the  time  for  the  operation. 

It  is  but  fair  to  state  that  every  effort  was  made  to  induce  the  patient 
to  go  to  a  hospital,  the  advantages  being  explained  to  her  most  carefully, 
but  to  no  avail. 

Operation. 

December  24,  1893,  in  the  front  room  of  third-floor  apartment  of  a 
tenement  at  84  J^orfolk  Street,  Sanger's  operation  was  performed. 

jSTo  attempt  was  made  to  clean  the  room,  but  as  perfect  asepsis  as  possible 
was  observed  with  everj^'thing  that  came  directly  in  contact  with  the  patient. 

Ether  was  started  at  11.25  a.m.  ;  uterus  lifted  out  of  abdominal  cavity, 
11.51:  ;  child  and  placenta  delivered,  11.56.  Last  suture  in  uterus,  12.16 
P.M. ;  last  abdominal  suture,  12.56.  Operation  lasted  1  hour  and  11  minutes. 
Silk  was  used  for  all  sutures;  sterilized  water  for  washing  and  irrigation 
purposes.  Dressed  with  strip  of  iodoform  gauze,  then  sterilized  gauze  held 
in  place  by  firm  binder. 

Patient  rallied  quickly  from  ether,  but  on  following  day  developed  severe 
cough  with  profuse  purulent  expectoration.  On  the  night  of  the  fifth  day, 
her  temperature  reached  101.2  degrees;  pulse,  121;  respiration,  28.  Bowels 
were  moved  by  enemas,  and  the  cough  controlled  by  small  doses  of  code- 
ine and  muriate  of  ammonia.  On  the  sixth  day,  as  temperature  remained 
up,  it  was  thought  advisable  to  dress  the  wound,  and,  upon  doing  so,  a  small 
drop  of  pus  was  pressed  from  second  lower  stitch.  This  was,  therefore, 
removed  and  well  washed.  Temperature,  one  hour  later,  101  degrees, 
largely  due  to  the  very  nervous  condition  of  the  patient. 

On  the  seventh  day  the  lochia  was  scant,  and  composed  of  mucus  and 
pus.  All  the  abdominal  sutures  were  removed,  and  an  intrauterine 
douche  given  of  weak  bichloride  solution.  Patient  being  very  unruly  and 
complaining  of  pain  in  right  chest,  physical  signs  showed  simply  an 
extensive  bronchitis.  On  the  eighth  day  a  small  stitch  abscess  at  the  site 
of  third  stitch  was  opened  with  scissors,  and  irrigated  with  peroxide  of 
hydrogen.  Patient's  general  condition  satisfactory,  appetite  very  good,  and 
sleep  much  improved.  Cough  is  troublesome,  and  expectoration  purulent 
and  profuse.  From  this  time  on,  patient  steadily  improved.  Douches  were 
given  every  day,  and  her  general  condition  built  up  with  cod-liver  oil  and  iron. 

At  the  end  of  four  weeks,  patient  walked  to  the  Dispensary  perfectly  well. 

The  child  was  bottle-fed  from  the  beginning,  but  was  a  remarkably 
healthy  baby  until  the  summer  of  1895,  when  it  died  of  some  diarrhoeal 
disorder,  the  mother  failing  to  notify  the  Hospital ,  until  after  its  death, 
some  local  physician  having  been  called  in. 

An  examination  of  the  mother  two  and  one-half  years  after  the  opera- 
tion reveals  uterus  of  normal  size,  drawn  well  up  in  the  pelvis  by  adhesions 
to  the  anterior  abdominal  wall.  Menstruation  is  regular,  and  her  only  trouble 
seems  to  be  the  loss  of  her  child  and  an  inability  to  become  pregnant  again. 
18 


PREGXAKCY  AXD   LABOR   FOLLOWING  ALEXANDER'S 

OPERATION. 

By  James  W.  Markoe,  M.D. 


Previous  History. 

C.  N.  1,705. — An  English  woman;  age  29  years;  III.  para;  married; 
fii'st  menstruation  at  twelfth  year;  always  regular;  after  the  fourteenth 
year  accompanied  with  pain;  general  health  was  otherwise  very  good 
until  she  married,  when  there  developed  a  leucorrhoea,  to  relieve  which 
she  entered  a  hospital  and  was  operated  upon;  thereafter  her  symptoms 
improved.  Iler  history  since  marriage  shows  one  miscarriage  before  the 
o]ieration,  and  one  after.  The  dates  of  these  or  the  duration  of  preg- 
nancy were  not  ascertained. 

History  of  Present  Pregnancy. 

Last  menstruation  on  June  27,  1891;  first  felt  foetal  movements  in  the 
latter  part  of  September;  on  October  6,  1891,  she  applied  to  this  Hospital 
for  care  daring  her  coming  confinement.  The  examination  at  this  time 
revealed  two  scars  two  inches  long,  directly  over  the  inguinal  canal ;  uterus 
(h-awn  forward,  witli  greatest  diameter  transverse;  measurements  of  pelvis 
normal;  jxitient's  general  condition  good,  Imt  complained  of  dragging  pains 
radiating  ujjward  from  scars.     General  condition  amumic  and  weak. 

Record  of  Lauok. 

Regular  ])ains  l)on;an  about  11  o'clock  i-.m.,  April  14,  1892,  and  were 
very  severe  from  the  beginning;  face  presentation;  position  L.  M.  P.;  at 
2  o'clock  A.M.,  A])ril  15th,  the  membranes  ru])ture(l  sj^ontaneously;  chloral 
hydrate  and  moi-phine  wei-e  given  to  control  the  excessive  pain,  which  she 
referred  to  tlie  course  o I'  round  ligaments.  Api-il  IC,  1892,  at  12  o'clock 
P.M.,  forceps  were  applied  above  the  brim,  but  with  considerable  force  no 
advance  cf)uld  l)e  made;  tliey  were  removed,  and  podalic  version  per- 
formed under  ether  to  surgical  decree. 

Tlie  cliibl,  a  male,  weighing  jil)out  eiglif  .-uul  one-half  jiounds,  was  deliv- 
ered without  much  <limculty;  but  althounli  its  heart  beat  for  some  time 
afterwanis,  respiration  was  never  established.  Tiic  mother  made  an  unin- 
terruptc*]  recovery. 


YERSION. 
By  Austin  Flint,  Jr.,  M.D. 


Among  the  10,233  cases  delivered  by  the  Hospital,  exactly  20Y  were 
delivered  after  a  version  operation. 

This  is  a  frequency  of  one  in  49.43  cases.  Among  the  207  cases  observed, 
twins  occurred  15  times,  making  a  total  of  222  children  delivered.  In  some 
instances  cephalic  version  was  done  during  pregnancy ;  in  one  instance  it 
was  performed  twice,  and  the  case  finally  delivered  after  a  podalic  ver- 
sion. Including  twin  cases  and  the  instances  in  which  version  was  per- 
formed more  than  once,  there  were  214  operations  performed.  Of  these, 
14  were  cephalic  and  200  podalic  versions. 

All  of  the  cephalic  versions  were  done  by  the  external  method,  with  one 
exception,  done  by  the  combined  method,  and  nearly  all  the  podalic  ver- 
sions were  done  by  the  internal  method.  These  operations  were  performed 
in  tenement  houses,  often  in  desperate  cases,  and  under  the  worst  possible 
surroundings.  Many  of  them  had  previously  been  under  the  care  of  mid- 
wives,  or  of  physicians  not  connected  with  the  Hospital,  and  had  been  sub- 
jected by  them  to  manipulations  and  operations  which  had  not  been  suc- 
cessful. In  each  instance,  careful  antiseptic  precautions  were  observed,  but 
the  patients  were  without  the  advantages  of  skilled  nursing  subsequent  to  de- 
livery, which  has  such  an  important  influence  on  the  ultimate  results.  This 
is  especially  noticeable  in  the  results  for  the  children,  many  of  whom  would 
undoubtedly  have  survived  had  they  been  born  in  a  well-appointed  hospital. 

The  operations  were  performed  for  a  great  variety  of  causes,  and  in 
cases  presenting  complications,  including  almost  all  of  the  more  common 
accidents  in  midwifery. 

I  have  made  a  table  of  all  the  version  cases,  which  contains  so  much  that 
cannot  be  shown  to  advantage  in  any  other  way,  that  it  is  published  as  it  is. 
(See  pages  277-278.) 

In  the  214  cases  tabulated,  the  presentation  and  position  are  recorded 

as  follows: 

Presentation. 


Cases. 

Shoulder • 86 

Yertex 102 

Transverse 4 

Face 7 

Breech 4 

Brow 2 


Cases. 

Ear 1 

Arm,  foot,  and  cord 1 

Transverse,  feet  and  cord 1 

Not  noted,  including  twins 14 

Total 222 


276 


REPORT   OF   THE   SOCIETY   OF   THE   LYIXGIX   HOSPITAL. 


POSITK^N. 


Cases. 

L.  O.  A 63 

L.  Scap.  A 25 

R.  Soap.  A 1^5 

R.  O.  A IS 

R.  Scai>.  P 13 

R.  O.   V 13 

L.  Scap.   P 11 

L.  M.  P 4 


Cases. 

L.  O.  P 2 

L.  Sacrum  P 2 

L.  Sacrum  A 1 

R.  M.  P 1 

L.  M.  A 1 

R.  M.  A   1 

Xot  noted,  including  twins 42 

Total  222 


The  complications,  as  can  be  seen  by  referring  to  the  large  table,  are 
SO  numerous,  that  it  is  difficult  to  tabulate  them  or  to  separate  them  from 
the  indications.  In  many  cases,  the  most  serious  of  the  conditions  pres- 
ent is  put  down  as  the  indication,  and  the  less  serious  condition  under  the 
head  of  '*  Complications."'  For  example,  a  placenta  pr^evia  complicated  by 
a  shoulder  ])resentation  and  a  prola])se  of  the  cord  has  occurred  several 
times.  To  this  miglit  be  added  a  slight  pelvic  deformity  as  a  complica- 
tion, if  it  were  slight,  or  as  the  indication,  if  it  were  serious. 

A  list  of  indications  and  complications  has  been  made,  but  this  might 
be  changed  by  one  who  considered  the  complication  of  more  importance 
than  the  indication,  or  vice  versa. 

Bef(jre  tal>ulating  the  complications  and  indications  in  the  cases  of 
podalic  version,  a  brief  summary  of  tlie  cases  of  cephalic  versions  will 
render  the  tabulation  of  tlie  others  more  sim])le. 

There  were  fourteen  such  operations.  The  indications  and  results  were 
as  follows: 

1.  For  shoulder  presentation,  followed  hy  forcei)s,  which  were  unsuc- 
cessful, and  the  case  was  finally  delivered  hx  podalic  version. 

2.  For  shoulder  presentation  performed  twice  during  pregnancy,  after 
which  the  coi-d  |)rolapsed,  and  delivery  was  accomplished  after  podalic 
version. 

3.  For  transverse  presentation,  followed  by  pi-olapso  of  the  cord  and 
podalic  version. 

4.  In  a  twin  caso,  the  second  child  Ix'ing  changed  from  a  breech  to  a 
vertex. 

5.  Also  for  a  breech  presentation  in  a  twin  case. 

0.   Twin  case,  cephalic  versicm  atteini)ted,  delivery  by  podalic  version. 

7.  Ih'eech  presentation,  changed  to  vei-tex. 

8.  Twins,  second  eliild  transverse,  changed  to  vertex. 

0.    Fr)ra  slioulder  pi-esentation  in  a  Xaegele  ])elvis,  followed  l)y  forceps. 

10.  For  a  slioiddei"  |)reseiitation  in  a  case  of  placenta  })rievia,  followed 
by  iKxlalic  version. 

11.  For  a  shoulder  presentation,  done  six  weeks  antepartum. 

12.  For  a  transverse  presentation,  changed  to  a  vertex. 

13.  Breech  presentation  changed  to  vertex. 

With  ca.se  nundxT  two  counting  as  two  operations,  cephalic  version  was 


XIV.-VERSION    (PODALIC   AND   CEPHALIC). 


R.  Scat).  P. 
R.  Scap.  A. 
L,  Scap.  A. 


R.  Scap.  P, 
B.  Scap.  A, 


1,103  > 
1,175 
1,M  I 


1,253 

1,280  - 

1.331  ti 

1,424- 

1,475 

1,554 

1,573 


Breech  

j  Vertex.    1st  | 
I  2d  twin.     "  f 


R.  Scap.  P. 

R.  O.  A. 
R.  Scap.  P. 
L,  Scap.  A. 

L.  S.  A. 


L.  M.  P. 
L.  Scap.  P, 


SlioulUer  . . 

Brow 

\''ei-te.v .  . . . 

Shoulder"!! 

foot, ' 


L.  Scap.  P, 
L.  a*A' 


L.  O.  A. 
H.  O.  P. 
L.  O.  A. 

R.  Scap.  P. 

Ij.  O.  A. 
L.  Scap.  A 
I,.  O.  A. 

ii.  Scap.  A 


Shoulder ;  placenta  prfEvia  ;  prolapsed  cord . 
Shoulder  presentation 


Shoulder;  prolapsed  an 
Shoulder :  prolapsed  ar 

Forceps  failed 

Shoulder  presentation  . 


Placenta  praevia  and  hjemorrhage  , . , 

Prolapsed  cord 

Prolapsed  cord,  second  child 

Shoulder  presentation 

Prolapsed  cord  ;  contracted  pelvis  — 

Prolapsed  cord,  second  twin 

Placenta  prtevia 

lapsed  cord 

Shoulder  presentation 

Prolapsed  cord;  head  not  engaging.  - 
Shoulder  and  right  hand. 


Prolapsed  cord  ;  pulsation  feeble  . 

Shoulder  and  breech 

Shoulder  presentation , 

Breech  ;  displacement  of  fcetal  part 

Second  twin,  prolonged  labor 

No  advance 

Shoulder  presentation 


Prolapsed  cord  (forceps) 

Midwife  case 

Placeutii  pi-ievia 

Perineum  torn  (forceps  tried) 

Jlidwife  and  outside  physician  had  failed  to  deliver  case 

Cephalic  and  forceps,  contracted  pelvis. .'. 

Mother  suffered  from  hiemorrhage  and  shock  from  I 
growths  on  cervix f 

Right  arm  and  leg  extended  ;  prolapsed  cord 

i,  immature 

Hydraranion 

Phthisis;  twins  

Prolapsed  feet  and  cord 

Contracted  pelvis ;  forceps  failed  . 
""    '  '  to  pulsate'    " 

Hex  head . 


Ruptured  I 
Cephalic  vc 


prolapsed  hand  . 
prolapsed  cord  .. 


Second  child 
No  record.. 
Shoulder  pr 

Position  persistent ; 


Mother  in  collapse;  pr( 


Albuminuria 
Exhaustion ;  t 
\  Prolonged  i 


Prolapsed  cord  and  ruptun 


Shoulder  prt  _ 

Prolonged  labor;  brow  pr 

'    r''eak  pains  ;    prescntiit 

R.  S.  P  ;  and  arm  prol 

Prolapsed  cord 

Shoulder  presentation;  \<\. 


Shoulder  presentation;  pia^ 

Contracted  pelvis 

Severe  pains;  no  advance.. 


Metliod  of  Extraction  of  After-coming  Head, 


)  pulsate  before 


Both  feet  seized  ;  right  hand  . 
Left  foot  seized ;      "        "■      . 


Right  hand  _ 

Right  hand  and  left  foot  seized. 
Delivered  by  podalic  version  . , 
Right  hand  and  left  foot 

Left  foot 

Heads  pulled  off  by  grasp  of  ce 

Left  foot  . . . , 

Right  foot 

Both  feet ;  left  hand 

Right  foot ;  right  hand 


■ity. 


1  twice,  after  which,  podalic  . 


Both  arms  and  head  extended 

Cephalic  version,  followed  by  podalic. . 

Pi-olapsed  cord 

Both  arms  extended 

.p,„jn„  j  Fii-st,  shoulder;  podalic  versior 
iwint,  (  Second,  breech  ;  cephalic  versic 

Prolapsed  cord 

"'wins ;    one  delivered  by    manual  » 
breech ;  and  the  other  by  cephalic  \ 


Cephalic  \ 


n,  followed  by  podalic 


High  forceps  and  previous  Alexander's  operatic 
'  Right  arm  partially  extended;    placenta  pro 

cord  prolapsed  during  extraction 

Placenta  pniivia ;  arms  extended 

Prolapsed  cord  :  arms  extended 

Asphyxia  in  child 


No  record  (tedious) 

One  leg  and  arm  extended. 

Arms  extended    

Legs  e.vtended ;  arm^'M'Ti 


Induction  of  labor 

Extended  arm 

Extended  arms 

Arms  extended 

extended . 


s  extended.. 

As  indicated 

apsed  arm  ;  shock,  two  hours  postpartun 

Occipito-posterior  position 


Weak  pains  (second  twin)    

Shouluer  presentation 

Contmcted  pelvis  (symphysiotomy), , 

Prolapsed  arm 

Placenta  pitevia 

No  record 

Shoulder  presentation 


Shoulder  presentatinu 
Hremorrhage  (seve 


Placenta  pn_ 

Deformed  pelvis;  prolapsed  cord, . . 

Prolapsed  cord;  pulsations  weak. , . 

Placenta  pi"a?via  and  hemorrhage 


Right  ar 
Right  an 


'  First  child,  R.  O.  A.;  second  child,  face ;  attempt  to  flex  caused  prolapse  of  cord. 


Ha2morrliat;i;f^i;vc'ro  .. 
Twins;  forceps;  albuu. 

Prolapsed  arm  

Failure  forceps 


I,eft  ar 
Fractn 


;  occipito-posterior  pus. 


I ;  suspended  a 
ito-posterior  position. . 


Living;  temperature  101"  Liv 

"       fever Lstil 

well 'l,iv 


Living ;  well 

recovery 

Died  5  houra  postparti 
Living;  well 


Right  tiand  ;  left  f 


Right  hand ;  right  foot  . 


Left  hand 

Bight  hand 

Left  hand 

Forceps  to  after-coming  head 

trnal  cephalic  version  and  binder. 


One  leg 


E.\ternal  cephalic 


,.  followed  by  forceps. 


s.;  rupt.  uterus;  right  hand;  both  feet 


Right  hand  ;  both  feet. . 


Left  hand;  right  foot 


Died  3ti  hi*s.  postp.; 
Living;  fever 


Died  4  hours  postparti 


well... 


.  Cord  pulsiiting. 
.  Not  heard. 


.  Still-boniiE 
.  Li\nng.... 
,.  Still-born  , 

.  Living 


,  Both  living . 

.  Still-born... 
,  Both  living  . 


.  Heard  in  Iststage, 


Died  a')  m 
.  Living... 
.  Still-born 


t  Attended  for  two  hours  before  labor  by  midwife. 


XIV.-TEKSION    (PODALIC   AND    CEPHALIC).-(CoN 


L.  O.  A. 
[..  Scap.  j\ 


III. 

s 

II 

xiri. 

;« 

IX. 

It, 

V, 

"« 

1. 

III 

III. 

11. 

28 

TI, 

:«l 

IX. 

h 

IV. 

M 

VIII. 

a 

IX. 

ir 

IX. 

III. 

21 

III. 

-'■1 

Shoulder  presentatioo ;  prolapsed  cord  J 

Placepta  pnevia  

Prolapsed  cord 

Contracted  pelvis;  failure  forceps 


Shoulder  presentation 

"  "  prolapsed  core 
Contracted  pelvis ;  symphysiotomy. , 
Slioulder  presentation 


lapsed  liand 

ilapsed  cord 

Shoulder  presentation . 


Shoulder  presentation  . 


Shoulder  presentation 

Prolapsed  cord 

Deformed  pelvis ;  weak  fcEtal  heart . , 

Hydrocephalus 

Deformed  pelvis 

Prolapsed  cord 

Deformed  pelvis 

Rclampsia ;  prolapsed  cord 

-Shoulder  presentation 


Deformed  peh 
Prolapsed  con 
Prolapsed  u 


ine  inertia  and  eclampsia 

Shoulder  presentation , 

Prolapsed  arm ;  weak  UaUii  beart 


other;  weak  foetal  hear 


'lii: 

'i 

III. 
1. 

lio 
XI 

9 

11. 

:;7 

VII 

VI. 

:iK 

i) 

vn. 

'■'■' 

" 

Deformed  pelvis;  prolapsed  eord 

Shoulder  presentation 

Face  presentation 

Brow  presentation;  deformed  pelvis. 


iiiipendinfj  asphyx 


Prolapsed  cord 

Shoulder  presentation;  prolapsed' cord ^! 

]''ace  presentation , 

Fliit  pelvis;  failure  uterine  force 


IV. 

1. 

8 

X, 

» 

II. 

n 

X. 

V. 

I. 

3 
30 

9 
il 

Ill 

:'.-. 

IV. 

II. 
I. 

30 

Deformed  pelvis 

Placenta  pnevia 

Shouldor  presentation  . . . 

Small  pelvis;  failure  to  d 

Feet  and  cord  prolapsed  . 
Shoulder  presentation  ... 

Deformed  pelvis  (flat).!.! 


rb^*  forceps.. 


Symphysiotomy  . 
Induced  labor 


Arras  e.xtendcd. 


Method  of  E; 


of  After-coming  Head. 


Combined  (bipolar)  cephalic . 


irrhage;  prematurity.. 


x^ALr. «.  ..io,  iituivii .  iinec,  1.1  ttiii.ii;  threatened  eclampsi; 

Fractured  humerus  in  child 

Postpartum  hferaorrhae'e;  oceipito-posterior  position 
Prolapsed  hand  and  arm  ;  developed  pneumonia 


Oceipito-posterior  position 

Deformed  pelvis 

Oceipito-posterior  position  ;  exhaustion  in  mothei 

Left  arm  extended ;  mother  exhausted 

Mother  intoxicated 

Oceipi  to- poster 


Prolonged  labor  {! 


Plural  births  (twins). , 


Deformed  pelvis. . 


;  raembranesTiipturedSday 


x;  iiEemorrhagi 
n  second) 


Ruptured  i 

Symphysiotomy !..........!...!! 

Prolapsed  arm  ;  hBemorrhage ;  prematurity 

Symphysiotomy  in  previous  pregnancy,  1893. .'.'.'.'.'... 
Extended  arms  ;  left  arm  fractured ...  .... 

Deformed  pelvis  (justo-minor);  mother  pneumonia  , 

Flat  pelvis;  extended  arms 

Symphysiotomy  (attempted  forceps) 


Extended  legs  aiii  1  :ii- ■ - 

Armsext.t  no  pruyress;   liiiclurt^d  burner 

Prolapse  of  cord  and  left  hand 

Twins ;  prolapsed  arm 

Fracture  of  arm '" 

1  Failure  of  forceps  to  cause  head  to  e'u''. 

1     extended ;  oceipito-posterior  positionr 

Prematurity ;  rigii't arm  extended  '.'..'.'.'.'" 
Prolapsed  cord  and  hand 


Prolapsed  arm;  prematurity! 
Prolapsed  cord ;  hosmorrhage 


Arms  extended ;  both  clavicles  f 
I'ight  iliac  fossa,  bead  i 
xtended;  rishtlege 


Breech  i 

Left  a 

Left  arm  displaced  belTind  back" 


1  labor  two  days . 


.  Still-born 
.  Living  . . 


Living:  died  postparti 


Both  feet  . 
Right  foot , , 
Both  feet  . '. 


.  Died  postpartum:  ho3m.. 


.  DicdSodaysp.p.;  pneum.. 


External  cephalic  during  pregnancy. . 
Temperatureof  mother  103° 


.  Died  7  hours  postpartun 


.  Died  6th  day  postpart 


.  Forceps  failed ;  right  a 


.  Died  at  Bellevue  ♦ 


.  Died  6th  day  postpartun 


Died  2d  day  postp.;  feve 


Died  3  days  postpartum. , 


Died  6  houre  postparti 


.  Died  3d  day  postpart 


►  Died  at  Bellevue  23  days  postpartum,  or  14  days  after  discharge 


VEKSION. 


279 


performed  fourteen  times ;  in  seven  deliver}^  followed  naturally,  and  in  the 
other  seven  delivery  was  accomplished  by  means  of  some  other  operative 
procedure. 

What  has  seemed  to  be  the  chief  condition  present  has  been  recorded 
as  the  indication  in  the  following  cases  in  which  podalic  version  was  per- 
formed : 

Indications. 


Cases. 

Shoulder  presentation 82 

Placenta  praevia 13 

Prolapse  of  the  cord 35 

Deformed  pelvis 27 

Transverse  presentation 3 

Hydrocephalus 2 

Attempted  forceps  (failure) 4 

Attempted  forceps  after  cephalic 

version 1 

Attempted  forceps  in  a  face  pres- 
entation       1 

Face  presentation,  inconvertible.  1 
Vertex,  no  indication  recorded . .  1 
Face,  posterior  position  of  chin  .     1 

Collapse,  attempted  forceps 1 

Albuminuria,  threatening  symp- 
toms       2 

Eclampsia 4 


Cases. 
Exhaustion  of  patient,  arm  pro- 
lapsed    1 

Ruptured  uterus 2 

Brow  presentation 2 

Weak    pains,    and    spontaneous 

change  from  vertex  to  shoulder  1 
Presentation   of   arm,   foot,  and 

cord 1 

Vertex,  no  advance 4 

Haemorrhage 2 

Prolapsed  arm  (twins) 1 

Failure    induction    labor    (weak 

pains) 1 

Prola])sed  hand  and  arm 3 

Exhaustion,  weak  pains 3 

Face  presentation,  no  progress .  .  1 

Total  200 


Under  the  head  of  "  Complications,"  the  following  conditions  are  tabu- 
lated. It  will  be  noticed  that  many  of  the  complications  are  identical 
with  conditions  recorded  as  indications  in  other  cases. 

Complications. 


Cases. 

Prolapse  of  the  cord 30 

Extended  arm  or  arms 29 

Prolapsed  arm 30 

Haemorrhage  and  shock 20 

Twins 15 

Attempted  forceps 9 

Occiput  posterior  position 7 

Immaturity 6 

Leg  or  legs  extended  5 

Previous  cephalic  version 5 

Symphysiotomy 6 

Fracture  humerus 6 

Placenta  praevia 12 

Midwife  cases 4 


Cases. 

Deformed  pelvis 8 

Ruptured  uterus   3 

Forceps  to  after-coming  head  ...  3 

Pneumonia 3 

Hand  displaced  behind  head  ....  2 
Prolonged   labor   (more   than    3 

days) 2 

Patient  alcoholic 2 

Shoulder  impacted  (dry  labor)  . .  2 

Leg  prolapsed 2 

Hydramnion 2 

Deep  laceration  of  cervix 2 

Extreme  rigidity  of  ring  of  Bandl  1 

Prolapsed  arm  and  leg   1 


280 


REPORT   OF   THE   SOCIETY    OF   THE    LYING-IN    HOSPITAL. 


Complications. — (Confiu  iiecl. ) 


Cases. 

Phthisis 1 

Face  presentation  1 

Head  extended 1 

UiUMuia 1 

Craniotomy,  after-coming  head  .  1 

Child's  skull  fractured 1 

Albuminuria    and    threatened 

eclamjisia 2 


Cases. 

Induced  labor 1 

Rigid  cervix  (undilatable) 1 

Incision  of  cervix   1 

Anencephalus 1 

Hydrocephalus 1 

Total L>30 

No  complication  other  than  the 
indication 45 


More  than  three-quarters  of  all  cases  were  complicated,  230  complica- 
tions occurring  in  162  deliveries,  and  but  -15  cases  that  were  not  complicated. 
This  has,  of  course,  a  very  important  bearing  n]wn  the  mortality  rate, 
not  only  for  the  mothers,  but  for  the  children. 

There  were  fourteen  maternal  deaths,  divided  as  follows: 


Cases. 

From  rupture  of  the  uterus 3 

Shock  and  haemorrhage 7 

Pneumonia 1 


Eclampsia 
Sepsis .... 


Cases. 
...  .   1 

<■>, 


Total 14 


Of  the  222  children,  149  were  born  alive,  65  were  still-born,  and  8  died 
during  the  puerperium. 


Cause    of   Death    in    Still-Bokn   Children   Delivered 

Version. 


AFTER     PODALIC 


Table  No. 
Cases. 

Prolapsed  cord 20 

Shoulder  presentation  (uncompli- 
cated)      6 

Shoulder   presentation,    arm    dis- 
placed ]iosteriorly     2 

Shoulder    presentation,    extended 

arms 1 

Shoidder  ])resentation,  hajmorrlL  .   1 
Deformed  pelvis 7 


Deformed  pelvis  and  haemorrhage.  1 
Deformed     pelvis    and     fractured 

skull 1 

Deformed  pelvis  and  craniotomy, 

after-corning  head 1 

Deformed    pelvis    and     ruptured 

uterus 1 

Placenta  j^rajvia 4 


Cases. 
Placenta  praevia  and  immaturity 

(one  case  of  twins) 3 

Placenta     i)r£evia    and    extended 

arms 1 

Eclam])sia  (one  case  of  twins) ....  4 

Attem})ted  high  forceps ...  2 

Forceps,   after-coming   head,  and 

extended  arms 1 

Ruptui'ed  uterus 1 

Haemorrhage 1 

Iliumorrhage  and  prematurity  ...  1 

After  cei)lialic  version 1 

Hydrocephalus 2 

Anence])lia]us 1 

No  cause  assigned      2 

Totid 65 


VERSION.  281 

In  inan}^  of  these  cases  the  child  Avas  dead  before  operating.  No  foetal 
heart  could  be  heard  in  85  instances,  or  in  more  cases  than  the  total  num- 
ber of  still  births.  The  cause  of  still  birth  can  be  assigned  to  accidents  in 
every  instance,  excepting  two. 

Cause  of  Death  in  Children  Dying  During  the  Pueepeeium,  Delivered 

BY  PoDALic  Version. 

There  were  seven,  the  circumstances  of  which  are  as  follows  : 
One  died  six  hours  postpartum,  a  premature  child,  in  a  case  of  placenta 
praevia. 

One  died  after  a  few  moments,  in  a  placenta  prsevia  case. 
"       "     25  minutes  postpartum,  in  a  placenta  prasvia  case. 
"       "     3  days  "  in  a  case  of  deformed  pelvis. 

"       "     5  days  "  "  prolapsed  cord. 

"       "     2     "  "  "  face  presentation. 

"       "   •  6     "  ''  no  cause  assigned. 

Among  these  cases,  also,  the  fatal  results  can  be  ascribed  to  accidents 
in  delivery,  in  all  but  one  instance,  and  w^ere  not  due  to  the  operation  itself. 

Placenta  prsevia  is  a  condition  important  enough  to  demand  special 
consideration. 

The  cases  which  appear  in  this  table,  however,  are  included  in  a-  special 
article  elsewhere  in  the  report,  so  that  the  results  need  not  be  repeated. 

Prolapse  of  the  cord  is  a  condition  which  complicated  the  delivery  64 
times.  There  were  undoubtedly  other  cases  in  the  service  of  the  Hospital, 
which  do  not  appear  among  version  operations. 

The  routine  treatment  in  such  cases  is  reposition  where  the  conditions 
are  favorable.  When  conditions  are  unfavorable,  by  reason  of  complica- 
tions, or  when  attempts  to  replace  the  cord  fail,  version  is  usually  done. 

Although  shoulder  presentation  or  placenta  prasvia  frequently  occurred 
among  these  64  cases,  42  children  survived,  20  were  still-born,  and  2  died 
during  the  puerperium. 

To  tabulate  the  complications  in  the  42  cases  of  living  children  would 
involve  useless  repetition.  A  table  of  the  complications  in  the  20  cases  of 
still  births  has  been  made,  with  an  idea  of  explaining  the  fatal  results. 

Still  Births  in  Cases  of  Prolapsed  Cord. 

Cases. 

Complicated  by  shoulder  presentation 5 

' '  a  deformed  pelvis 4 

' '  extended  arms 3 

"  ruptured  uterus 2 

"  depression  child's  skull 1 

"  forceps  to  after-coming  head 1 

No  complications 4 

Total 20 


282  REPORT   OF   THE   SOCIETY    OF   THE    LYIXG-IX    HOSPITAL. 

The  death  which  occurred  on  the  lifth  day  after  delivery,  in  a  case  of 
prolapsed  cord,  could  not  be  traced  to  any  special  cause. 

Such  a  summary  of  cases  in  which  version  was  performed  develops 
nothiuo-  new  in  re^iard  to  the  treatment. 

The  operation,  its  causes,  and  the  results  for  the  mother  and  child  are 
submitted  in  the  form  of  a  statistical  report.  In  the  opinion  of  the  writer 
it  proves  the  fact  that  it  is  possible  to  obtain  good  results  under  unfavor- 
able surroundings,  when  care  is  taken  to  observe  antiseptic  precautions  in 
operating.  Among  all  the  cases,  but  one  maternal  death  ca.n  be  ascribed 
to  sepsis.  Two  others  were  unavoidable,  and  had  no  bearing  on  the  oper- 
ation whatever;  namely,  the  cases  of  pneumonia  and  eclampsia.  The 
remainder  were  caused  by  shock,  haemorrhage,  and  ru])tured  uterus. 

It  is  but  fair  to  again  tlirect  attention  to  the  fact  that  man}^  of  these 
cases  did  not  come  under  the  care  of  the  Hospital  until  late.  Everv 
obstetrician  can  recall  the  desperate  nature  of  cases  sent  to  hospitals  as  a 
last  resort,  and  neglected  up  to  the  time  that  they  are  admitted. 

The  mortality  rate  from  all  causes,  in  cases  of  version,  was  G^  per 
cent. 

I  do  not  wish  to  be  understood  as  advocating  treatment  of  serious  cases 
in  the  tenements  rather  than  transferring  them  to  a  properly  equipped  hos- 
pital. Such  a  course  would  needlessly  sacrifice  many  lives.  On  the  other 
hand,  when  it  is  impossible  to  operate  under  favorable  surroundings,  good 
results  may  be  expected  under  even  the  most  unfavorable  conditions,  in  a 
great  majority  of  cases. 

The  results,  whatever  they  may  be,  depend  directly  upon  the  ability  to 
carry  out  antiseptic  princi})les  and  api)ly  them  to  obstetric  surgery. 


FKACTURES  IN  THE   NEW  BORN. 
By  Churchill  Carmalt,  M.D. 


Among  the  liistories  of  10,233  deliveries  in  the  Lying-in  Hospital  and 
Dispensary,  delivered  by  1,631  men  (1,545  students,  86  staff — the  staff, 
however,  responsible  for  all  fractures  recorded),  there  are  histories  of  40 
infants  suffering  from  42  fractures.  Five  craniotomies  and  embryotomies 
are  included  in  that  number.  This  is  a  ratio  of  one  fracture  to  each  250 
deliveries  and  to  each  six  accoucheurs,  a  frequency  much  greater  than 
ordinarily  noted. 

Of  these  injuries  the  writer  has  personally  seen  twenty-three,  some  of 
them  not  included  in  the  statistics  here  presented,  but  in  all  the  diagnosis 
rested  upon  the  joint  opinion  of  the  attending  surgeon,  at  least  two  mem- 
bers of  the  Hospital  staff,  and  one  or  more  students.  Like  all  statistics, 
these  are  only  approximately  correct;  as  cases  individually  they  may  be 
useful.  The  preponderance,  mentioned  by  most  writers,  of  fractured 
humeri  is  apparent  in  the  following  table: 

Fractures  of  the  skull Living  children 5 

"  "  "     . Dead  "       2 

Craniotomies  and  embryotomies .  .      "  "       5 

Fractures  of  the  jaw "     child 1 

"  "      clavicle Living  children 2 

"  "      humerus "  "        18 

"  "  "       Dead  "        6 

'^  "     forearm,  scapula, 

ribs,  sternum, 

pelvis  0 

"  "      femur Living  children 1 

Multiple  Fractures  : 

Fractures  of  both  clavicles Living 1 

Fractures  of  skull  and  humerus ...       "     1 

The  relation  of  fractures  to  operative  procedures  is  shown  in  the  fol- 
lowing table.  In  cases  of  abortion  no  position  is  recorded,  so  that  these 
statistics  in  regard  to  the  fcetus  refer  only  to  those  that  have  reached  at 
least  seven  months'  development.    As  the  number  of  still  births  in  any  hos- 


284 


REPORT   OF   THE   SOCIETY   OF   THE    LYIN'G-IN    HOSPITAL. 


pital  statistics  diminishes,  there  Avill  ])robably  be  au  increase  in  the  fcBtal 
ilamas:e  or  the  number  of  induced  hxbors. 


Totals 

Low  forceps 

High  forceps 

Attem])ted  high  forceps 

and  vei'sion 

Embryotomy  and  era 

nioclasm 

Podalic  version 

Breech  presentation .  .  , 
Sh(  (ulder  presentation , 

Phiral  births 

Vertex 


X 

i    . 

6 

M 

u 

«3 

5 

«5 

3 

S 

!i 

w 

f-l 

•  l-< 

o  ^ 

o} 

1— 1 

O 

f=H 

pq 

+2 

=4-1 

l+H 

=fH 

w 

O   bi 

o 

O 

§3 

B 

O 

M     CC 

13    O) 

5^ 

9 

Xi 

p 

2 

tsS 

Vs 

nd     >-; 

^ 

:3 

S        . 

1 

1— 1 

y 

^ 

o 

15  ^ 

^1 

o 

^ 

W 

^ 

Ph 

<1 

P 

P 

[^ 

P^ 

10,233 

359 

110 

218 

417 

215 

? 

13 

24 

240 

29 

2 

1 

0 

? 

0 

1 

141 

16 

0 

0 

0 

? 

4 

0 

13 

T 

0 

0 

0 

1 

5 

0 

1 

5 

5 

1 

1 

0 

0 

3 

(5) 

0 

148 

35 

11 

3 

0 

9 

14 

2 

11 

341 

59 

27 

7 

0 

31 

? 

2 

9 

91 

23 

1 

0 

2 

y 

(1) 

(5) 

161 

35 

7 

3 

0 

35 

2 

(1) 

(1) 

8,495 

211 

5 

0 

126 

? 

(4) 

(10) 

O 


(1) 

1 

2 

(1) 
0 

(2) 


All  of  these  fractures  were  due  to  manual  interference  in  delivery 
under  conditions  that  would  have  sacrificed  the  child  and  perhaps  the 
mother  without  such  interference.  Nevertheless,  o])erative  ignorance  on 
the  ])art  of  the  obstetrician  has  been  an  etiological  factor.  Caused  by 
ignorance,  I  would  class  those  fractures  of  the  skull  due  to  pressure 
through  the  alxlominal  wall  in  efforts  to  express  the  after-coming  liead,  a 
large  number  of  the  fractures  of  the  humerus  in  breech  extractions,  and 
multi])le  fractures  in  cases  where  symphysiotomy  or  Ctesarean  section 
should  have  l>een  chosen,  instead  of  some  more  usual  obstetric  jirocedure 
violently  performed.  There  were  34  fractures  among  506  breech  ex- 
tractions and  presentations,  against  8  fractures  among  all  other  modes  of 
delivery. 

Fractures  in  the  new  Ijorn  diflfer  from  other  fractures  only  in  their 
etiology,  rapid  repair,  perhaps  tlu;  infrequency  of  com[)lications,  and  in  the 
application  of  apparatus  to  such  small  bodies. 


Definition  (/>/•.  Stiinson). 

"A  fracture  is  a  solution  of  contimiitv  in  the  more  solid  connective 
tissues,  bone  and  cartihige,  such  occurring  '  s))ontaneously '  in  healthy 
tissues,  or  'pathologically'  in  diseased  tissues;  not  a  very  technical,  but 
convenient,  statement." 


FRACTURES    IX    THE   NEW    BORN.  285 

Classification   {Stimson). 

Incomplete  (comnion  in  infants): 

a.  Fissured  (leading  to  periosteal  infection), 

h.  Green  stick  (deformity  of  a  long  bone  with  fissure). 

G.  Depression  (no  macroscopic  solution  of  continuity). 

d.  Separation  of  splinter  or  apophysis. 
Complete,  divided  as  to: 

a.  Direction  of  line  of  fracture  (usually  transverse  in  infants). 

h.  Seat  of  fracture  anatomically  (epiphyses,  shaft,  etc.). 

c.  Relation  to  joints  (intraarticular  are  not  common). 

d.  Mode  of  production  (direct  violence,  etc.). 

e.  Number  of  fractures  (multiple  are  common  in  real  intrauterine 

fractures). 
Compound : 

a.  "With  ordinary  wound  of  skin. 
h.  Gunshot  (all  so  far  reported  in  new-born,  dead). 
Displacement  may  be  transverse  or  lateral,  angular,  rotary,  by  over- 
riding, impaction,  crushing,  or  direct  longitudinal  separation. 

Etiology. 

Etiology  will  be  studied  more  particularly  under  the  head  of  fractures 
of  the  individual  bones.  Usually  these  fractures  are  the  results  of  manual 
or  instrumental  interference,  undertaken  to  change  the  position  of  a  dis- 
placed limb  or  head  of  a  foetus  in  utero,  to  supplement  the  insufficient 
expulsive  power  of  the  uterus,  or  to  hasten  delivery  in  conditions  menac- 
ing the  life  of  the  mother  or  the  child. 

Whether  in  instrumental  interference  or  by  uterine  force,  strain,  supe- 
rior to  the  resistance  of  foetal  bone,  exerted  from  without,  through  a 
comparatively  short  period  of  time  and  with  varying  leverage,  is  the  cause 
of  all  these  fractures. 

Fractures  by  violence  of  uterine  force  alone,  when  a  limb  is  caught 
between  the  hard  parts  of  the  mother  and  the  body  of  the  child,  are  very 
rare ;  but  three  cases  are  cited  by  Hamilton,  and  the  mechanism  is  carefully 
explained  by  Reynolds.  Fractures  of  the  skull  pushed  by  uterine  force 
alone  through  anomalous  pelves  are  reported  by  Rosinski. 

The  resistance  or  elasticity  of  foetal  bone  studied  under  the  dissimilar 
conditions  of  life,  death,  time  of  pressure,  point  of  pressure,  differing 
kinds  of  force,  and  long  and  short  leverage,  is  hard  to  estimate.  It  is 
partially  decided  for  adult  bones  to  be  about  that  of  cast-iron.  In  experi- 
ments on  the  dead  foetus,  now  undertaken  at  this  Hospital,  these  elements 
shall  be  studied  for  a  future  report.  A  force  of  about  twenty  pounds 
applied  for  one  minute  on  the  humerus  of  a  still-born  male  child,  with  a 
leverage  of  one  and  one-half  inches  on  each  side  of  a  fixed  point,  fractured 
the  humerus  transversely.     (Experiment  of  writer,  December  2,  1896.) 

Uterine  force  is  estimated  at  from  six  to  three  hundred  pounds.  In 
difficult  labors,  as  in  nearly  all  of  those  deliveries  in  which  fractures  occur. 


286  REPORT   OF   THE   SOCIETY    OF   THE    LYING-IN    HOSPITAL. 

the  force  exerted  by  the  uterus  ou  u  circle  lour  auil  one-half  inches  in  diam- 
eter— the  dilated  os  uteri — is  at  least  sixty  pounds.  If  deflected,  by  the 
pi-essure  of  the  accoucheur's  linger  or  instrument,  against  a  point  on  a  limb 
or  a  flat  bone  lixed  in  the  uterus  or  pelvis,  such  a  force  is  more  than  sufli- 
cient  to  fractui'e  that  bone.  Any  nuinipulation  of  insignificant  force  itself, 
permitting  point  of  support  as  a  fulcrum  for  lever  made  of  foetal  bone, 
mav  cause  a  breaking  pressure  to  be  exerted  against  the  arms  of  such 
lever.  Experiments  as  to  uterine  force  are  vitiated  for  the  most  part  by 
the  difficulty  in  estimating  the  resistance  to  be  overcome.  Haughton's 
]>urelv  theoretical  calculations  are  immensely  too  large,  as  shown  by  Mat- 
thews Duncan,  whose  estimate  of  sixty  pounds  has  not  been  disproved. 
Proofs  of  the  truth  of  these  estimates,  it  is  hoped,  will  be  ready  for  the 
next  Report. 

Predisposing  Causes  of  Fracture. 

We/'(//if  of  Child. — As  shown  by  this  series,  the  larger  children — all  but 
one  over  Of  pounds  at  birth — are  much  more  liable  to  fracture  than  their 
leaner  fellows. 

Se.c  of  Child. — As  a  corollary  to  the  above,  the  weight  of  males  aver- 
ages somewhat  greater  than  that  of  their  sisters,  and  on  that  account 
males  are  more  liable  to  fractures.  Also,  the  children  of  multiparse  are 
larger  than  those  of  primipara?,  and,  therefore,  more  liable  to  injury. 

Early  os><iJi<:ation  of  bones,  particularly  the  skull,  predisposes  to  frac- 
tures. The  cause  of  this  condition  is  unknown,  unless  chronic  periostitis 
may  lead  to  it.  Pare  diseases,  myositis  ossificans  multiplex  progressiva, 
might  cause  fractures. 

Si/philis  renders  the  nutrition  of  Ijones  ])oor,  l)ut  the  children  are  usu- 
ally small  and  their  delivery  easy.  If  syphilis  causes  hydrocephalus,  that, 
of  coui-se,  might  demand  craniotomy,  and  sy]ihilitic  osseous  dystrophy  or 
osteopsathyrosis  may  cause  a  separation  of  e])iphyses. 

Rachitic  (rare  in  the  new  born)  may  ]^redispose  to  fractures.  It  is 
claimed  to  be  the  most  common  cause  of  real  intrauterine  fracture.  jSIyx- 
cedema  or  cachexia  struinipriva  in  the  mother  (Kocher)  renders  the  child 
liable  to  rachitis,  and  so  possibly  more  liable  to  fracture.  As  Avith  syphilis, 
these  children  are  usually  pooi'ly  nourislied,  and  their  delivery  is  accom- 
])lished  with  little  dilliculty.  Intrauterine  cretinism,  associated  as  it  is  with 
rachitic  malnutrition  and  malformed  skulls,  would  ]u-ol)ably  predispose  to 
fracture.  Ilaig  asserts  that  even  an  iiilici-ited  tendency  to  tlie  uric  acid 
diathesis  would  render  bones  brittle. 

Poxiilon  of  the  fdun  in  iitero,  i)r('ech  presentation,  transverse  ])osi- 
tions,  and  any  condition  requiring  podalic  version,  Avith  its  consecutive 
l)reech  extraction,  seems  a  special  menace  to  the  integrity  of  the  child's 
lim])s  and  vertebrte  (84  cases  among  HoO  such  ])ositions).  Pelvic  deformi- 
ties and  uterine  inertia,  in  conditiiMis  necessitating  tin;  use  of  forceps,  are 
more  liabhj  to  fracture  the  skull,  thorax,  and  i)elvic  girdle. 

Thr  rlniiiixfry  of  fitftl  hotir  aud  the  ]»atliology  of  such  conditions  as 
early   union   of  sutun;  lines,  carlv  ossili(;it  i<»n.   iIk-   inlluence  of  tlu^  h3'po- 


FRACTUEES   IN   THE   NEW    BORN.  287 

physis  cerebri,  tlie  thymus  and  thyroid  glands  on  bone  nutrition,  are  at 
present  too  obscurely  understood  to  indicate  anything  save  possible  defects 
in  present  pathological  teachings. 

Bibliography. 

Uterine  force. 

Haughton:  Dublin  Quart.  Jour.  Med.  Sciences,  1870,  xlix.,  p.  459. 

Duncan :  Contributions  to  the  Mechanism  of  Natural  and  Morbid  Par- 
turition, 1ST5,  p.  108. 

Kehrer:  Beitriige  zu  Yergleich  und  Experiment.  Geburts  Kunde,  ii.,  p. 
119. 

Schatz:  Archiv  flir  Gynak.,  1872,  s.  64. 

Cocq,  Archiv  de  tocologie  et  de  gynecologie.     Paris,  1894,  p.  335. 

Strain  of  Infant  Bone. 

Joulin :  Traite  Complet  des  Accouchements,  p.  447. 

Tillman's  Principles  of  Surgery  and  Surgical  Pathology  (translated  by 
Rogers  and  Tilton).     N.  Y.,  1894,  p.  569. 

Pepaie. 

Malgaigne  (1840)  in  his  clinical  lectures  said  that  "  bone  for  bone  and 
fracture  for  fracture,  repair  in  children  requires  only  half  so  much  time  as 
it  does  in  adults. ' '  All  subsequent  writers  agree  with  him,  as  do  the  his- 
tories of  cases  here  recorded.  "Breaks  of  lower  limbs  take  more  days  in 
healing  than  those  of  upper  limbs ;  of  the  latter  more  than  of  the  skull ; 
of  midshaft  more  than  of  epiphysis;  of  bone  with  permanent  displace- 
ment or  mobility  more  than  of  fragments  in  accurate  apposition."  (Stim- 
son,  p.  113.) 

The  reasons  for  such  active  repair  are  the  greater  proportionate  blood 
supply  to  infant  bones,  the  greater  thickness  of  the  osteogenetic  layer 
(twice  that  of  adult  bone,  according  to  Cohnheim)  of  the  infant's  perios- 
teum and  the  weaker  musculature  of  the  foetus,  causing  little  spasm  and 
small  tendency  to  displacement. 

Bibliography. 

Zeigler:  Text-book  of  Special  Pathological  Anatomy,  ]^ew  York 
(translation  from  eighth  German  ed.),  1896,  p.  161. 

Signs. 
Ohjective : 

Deformity— angular,  longitudinal. 

Abnormal  mobility. 

Crepitus  (not  easily  made  out  in  infants). 

Spasm  (not  common),  muscular  twitching. 

Loss  of  function;  pseudo-paralysis. 
Subjective  : 

Tenderness. 

"  Night  cry  "  (very  common). 


288  REPORT   OF   THE   SOCIETY   OF   THE    LYIXG-IX    HOSPITAL. 

After  repiiir  has  taken  place,  the  limb  may  be  shruuken,  muscles  wasted 
and  feeble,  skin  ilrv,  with  tendency  to  congestion  and  desquamation,  stiff- 
ness in  neighboring  joints  (adhesions?),  callus,  deformity,  paralysis.  These, 
liowever,  dis;\]i])ear  so  ra])idly  in  infancy  that  at  the  end  of  two  or  three 
months  even  a  marked  deformity  may  entirely  disappear,  as  in  a  fracture 
of  the  skull,  in  a  case  cited  below. 

In  diagnosis  from  malformations,  defects,  and  paralysis,  Rontgen  pho- 
tography may  prove  a  great  help,  although  the  EOntgen  photographs  pre- 
sented on  pages  297  and  303  are  not  very  satisfactory.  More  familiarity 
with  the  fluoroscope  will  probably  obviate  this  defect. 

Treatment. 

Of  recent  yeai's  immobilization  in  some  retentive  apparatus  has  been 
the  almost  universal  practice  in  treatment  of  fractures.  It  is  accom- 
])lished  with  considerable  difficulties  in  children,  where  points  of  fixation 
are  few,  pressure  irritates  the  skin,  and  the  dressings  are  continually  wet 
from  urine  or  careless  bathing.  These  appliances  are  made  from  plaster 
of  paris  (gy])sum),  silicate  of  soda,  wrapjiing-paper  in  la3^ers  moistened 
with  glue,  heavy  cardboard  fastened  with  adhesive  plaster,  preparations 
which  become  pliable  on  the  application  of  heat  or  moisture,  celluloid  in 
acetone  (lately  much  lauded).  The  last  two  are  not  always  within  easy 
reach,  and  the  celluloid  is  inflammable. 

It  appears  to  be  satisfactorily  established  through  the  writings  of 
Lucas-Cliampionniere,  1SS9,  in  France;  Landerer,  1891,  in  Vienna;  and 
Kendal  Franks,  1891,  in  Dublin,  that  massage  as  practised  in  Egypt, 
Arabia,  and  India  for  centuries  (Slatin  Pasha)  "promotes  comfort,  and  at 
least  expedites  restoration  of  function  when  there  is  little  displacement  of 
fnigments,  when  the  skin  is  uninjured,  and  when  the  bone  is  not  too  thickly 
covered  with  muscles,  as  in  the  neighl)orhood  of  joints."  (Stimson  in 
Sajous's  Annual,  1895.)  This  would  indicate  that  fixation  apparatus  may 
be  removed  daily  and  the  child  cleansed  Avithout  the  resulting  harm  often 
claime<l.  Because  many  untreated  cases  ([)roljaljly  the  majority)  recover 
with  perfect  function  and  without  deformity,  such  removal  of  dressing 
may  ])(i  advised  under  ])roper  restrictions.  Massage  increases  the  amount 
of  callus,  but  certainly  maintains  the  nutrition  of  muscles. 

Complications. 

Permanent  deformiiy  (common  only  in  frontal  depressions  apparently). 

Exuhcrant  and jM'inful  callus  (due  to  malposition  of  fragments,  inter- 
fK)sition  of  soft  parts,  syphilis,  scurvy,  rachitis  (?),  when  the  embryonal 
bf>ne  stage  persists)  is  a  common  complication,  but  disappears  rapidly  with- 
out treatment. 

pHevflarfhroHw^  very  rare  in  these  fractures.     (Bruns.) 

Inrhiiotm  of  nerven  hi  callus  and  ])aralysis  due  to  injury  <jf  nerves  are 
reporte<l  by  I)r.  Weir  ^litchell  (Injury  of  Nerves,  p.  104). 


FRACTURES   IN   THE    NEW    BORN.  389 

Sarcoma  in  callus  is  reported  by  Bruns  (only  case  reported). 

Stiffness  of  joints  and  limbs  and  atrophy  in  segments  above  and  below 
the  fracture,  noted  by  Gosselin,  are  certainly  very  uncommon  in  the 
fractures  of  infants. 

Ilcemorrhage,  exceedingly  common  on  account  of  infant's  thin  arterial 
walls,  the  special  danger  of  fractures  of  the  skull. 

J^at  emholisin  (no  case  reported). 

(Edema  and  thromhosis  seem  to  be  moderately  common,  but  disappear 
rapidly. 

Diminished  growth  from  so-called  epiphyseal  injury  is  more  probably 
due  to  chronic  osteitis  or  osteomyelitis,  with  early  ossification. 

Acute  ej)ij)lnjsitis^  Dr.  C.  B.  Poore  maintains,  is  often  an  infection  of 
unrecognized  fracture  from  a  suppurating  umbilicus,  infected  pin-prick, 
etc. 

Gangrene^  especially  common  in  the  3^oung,  so  that  pressure  from  ban- 
dages must  be  carefully  watched.     (Stimson,  Fractures,  p.  141.) 

Tuherculosis  of  hone  in  the  3^oung  seldom,  if  ever,  follows  a  fracture, 
as  the  injury  is  productive  of  such  active  cell  prolification  that  this  very 
activity  will  hold  in  abeyance  the  pathogenic  action  of  tubercle  bacilli. 
(Yolkman,  quoted  by  Senn.) 

Nervous  delirium^  quite  like  the  milder  types  of  delirium  tremens  in 
adults,  must  be  moderately  common,  as  the  writer  has  seen  two  cases  in 
children,  following  fracture. 

The  literature  of  complications  is  very  meagre,  and  in  the  discussion 
following  Dr.  Lovett's  paper  in  Boston  in  1893,  most  of  the  men  denied 
having  seen  any  complications. 

Bibliography  on  Fractures  in  the  Kew  Born. 

Parvin:  in  Keating's  Cyclopaedia  of  Diseases  of  Children,  1889,  vol.  i., 
p.  258. 

Lovett:  Boston  Medical  and  Surgical  Journal,  1893,  March  30. 

Kuestner:  Die  Typischen  Verletzungen  die  extremitaetenknocken  des 
Kindes  durch  den  Geburtshelfen,  Halle,  1887. 

Brothers:  Infantile  Mortality  during  Childbirth  (W.  F.  Jenks,  prize 
essay),  Philadelphia,  1896. 

Gurlt:  Lehre  von  Knocken  bruchen,  Berlin,  1862. 

Stimson :  Treatise  on  Fractures,  New  York,  1878. 

Hamilton:  Fractures  and  Dislocations. 

St.  Germain:  France  Medicale,  Paris,  1879,  xxiv.,  89. 

Plunlvett  (J.  D.):  IS'ash^alle  Jour.  Med.  and  Surg.,  1879,  xxiv.,  p.  69. 

Delove:  Diet.  Encj^cl.  de  sc.  Medicale,  Paris,  4  s.,  iv.,  p.  201. 

Leutze:  Berliner  Klin.  Wochenschrift,  1880,  xvii.,  740. 

Dubreuil:  Gaz.  Hebd.  de  sc.  Med.  di  Montpellier,  1883,  v.  241. 

Keed:  Brit.  Med.  J.,  London,  1881,  p.  639. 

Korber  (G.  J.  L.):  Die  Knocken  verschadegungen  der  Fruchte  wahrend 
die  Schwangerschaft  wahrend  und  nach  der  Geburt.,  Svo,  "Wurzburg,  1835, 
19 


290  REPORT   OF  THE   SOCIETY   OF  THE    LYING-IN    HOSPITAL, 

Cieslewicz  (J.):  \'erletzungen  des  Fa^tus  diircb  ileii  Geburtshelfer, 
8vo,  Halle  (187(»). 

Diicournoau  (J.  E.):  Contribution  a  retiule  des  lesions  des  foetus  dans 
les  presentations  spuutauees  de  Textremite  pelvienne  et  dans  la  version, 
4to,  Paris,  1:S70. 

Iledinger  {C.  F.):  rel)er  die  Knocken-verletzungen  bei  Keugebornen 
in  niedic-inisb  gericbt  licber-IIuisicbt,  Svo,  Tubingen,  1833. 

Lapitzondo  (M.):  De  quelques  cas  le  lesions  trauniatique  eprouvees  par 
le  ftvtus  ])endant  raccoucbenient,  4to,  Paris,  1867. 

Pajot  (C.) :  Des  lesions  trauniatitpies  que  le  foetus  peut  eprouver  pendant 
accouchement,  8vo,  Paris,  1853.  Also  in  bis  Trav.  d'obstet.  et  de  gynecol. , 
Svo,  Paris,  1882,  p.  201-424. 

Von  Sassen  (O.):  Ueber  ^'erletzungen  des  Kindes  durcb  die  Wendung 
und  Extraction  oder  Expression  bei  Beckenendlagen,  Svo,  Berlin,  1874. 

Seitfert  (A.):  Ueber  Todesensacken  du  Kinder  wahrend  der  Geburt., 
Svo,  Berlin,  1873. 

Little:  London  Lancet,  1S61,  ii.,  p.  378-380. 

Oebler:  U.  Ztschr.  f.  Geburtsh.,  Berlin,  1836,  iii.,  383-396. 

Piedagnel:  Bull.  Acad,  de  Med.,  Paris,  1840,  v.,  203-215. 

Fkactuees  of  the  Skull. 

The  photograph  and  tracing  (Figs.  1  and  2)  sliow  the  conditions  exist- 
ing in  the  child  (C.  N.  26);  age  two  years.  Now,  after  five  years,  the 
conditions  remain  unchanged.  The  drawings  (Figs.  3  and  4)  indicate  more 
fully  than  the  history,  the  autopsy  of  C.  N.  255  (indoor  history)  and 
C.  N.  37S  (indoor  history). 

The  lettered  cases  are  noted  for  peculiar  features.  The  cases  from 
the  indoor  histories  and  later  outdoor  cases  are  preliminary  to  the  next 
report.     None  of  these  cases  are  included  in  the  statistics. 

Locality  of  the  Fractures. 

Parietal  depression  ainong  the  new  born,  Matthews  Duncan  and 
Rosinski  sav,  is  more  common  than  all  other  fractures  of  the  skull.  In 
the  .seventeen  infant  skull  fractures  seen  by  the  writer  (two  not  in  this 
series)  eleven  had  ])arietal  depression.  As  the  head  descends  with  the  long 
diameter  transverse  to  the  pelvis,  the  parietal  bones  are  exposed  to  pressure 
from  the  short  conjugate,  and,  low  in  the  pelvis,  to  pressure  from  forceps 
blades. 

Frontal  (hjn-rxxion^  Jennings  says,  persists  if  untreated.  This  record 
confirms  this  assertion,  one  case  thirty  years  old  still  showing  marked  de- 
pression, one  after  live  years,  and  one  aftei"  two,  while  no  purely  frontal 
depH'ssion  corrected  itself  jus  did  the  ])ai-i('tal,  occi])ital,  and  temporal 
di'pressions.  The  frontal  arch,  with  its  buttressed  base,  is  less  subject  to 
change  of  shape,  after  depression,  frcjni  intr;ui;inial  or  extracranial  pres- 
sure than  the  parietal  or  occi|>it;d   rcgioiis.      On  account  of  the  disfigure- 


■ 

« 

Numt«;r 

Iteconl. 

Previoua 
Cbildreil. 

10 

Para. 



Shorn  iillve 

s'luri. 

10 

I. 
VI. 

H.IIW 

r„illvc....  . 

,,,:„ 

rmilvo 

10 

IX. 

5,« 

Provloim 
liilii.rtluii. 

10 

1. 
11. 
111. 

n.,l,j..i' 

10 
10 

IV. 

li  

1 

"I'f!  j.'w.' 

M,._  AllB. 

10 
ICO 

1. 

I. 

I. 

rn...  Ill  HIT 

II. 
V. 

Jtlmm.i'i; 
N.  V.  II. 

IlllVOWltll 

iiliortliiiij 

1  llKui. 

10 

,,  8t:up.  A. 


im 

iMHu 

1  UllU 
1  ullv 

i- 

1,11,,., 

.0 

V. 

Jugate, 
4 J  tnclies. 


JllKUtC, 
li  in. 

inches. 


11     " 


Placcntii  pncviu 

via ;    displacc- 

montol'oliild. 

TwliiB  louItoU  (y; 

Jutting  lu'omoii' 
tijry. 

Juttlntr  promon- 
tory;   ulbumi- 


Jiittingpromoii' 

Jutting  promon^ 
yiHinall  pel- 
Jutting  promoii- 


Oliliqno    polvia; 
Il8|iliic<'il  ciilli 


Podnilc  version 
brcucli  exti-ac- 
lion. 

Symjiliyaiotomy 


Pod.  voi-sion;  iic 
couclium.  forefi 


bind  bead. 

Firatclilid  caugbt 
against  second, 

irms  and  logsc.v 


Narrow  pelvis.. 
Tetanic 


Recovery 


rigid  vagini 
NoneC?) 


None(?) 

Smnli   pelvis  and 


Arms  and  leg  ex- 
tended i      ereat 


Female 
Mule, 


Deatb;  6op- 
HecovQi'y . 


Good.. 
Good.. 


Female 
Male, 


on     tion;    ilntrers  iu 


-IDeluy  in  deiivcrylGoo.i., 


Miilpiisltloii  I'cc 
Sniiill    polvlH 


Breech  extraction 

1IIb:1i   forceps  un- 
verBion;  breecli 


Arms  extended;  1 


uterine  tetanus. 


See  under  Pmctures  or  Tibia  and  Fibula. 


nm  rce-|PodnI!o     version  slTotanic 


1.1    It.  0.1*.    Kllinohes.lJnUliiiTpnmn 

toi'y:  niiilpti 

I    tlon  fiutiis. 


,-|niKli  forceps  lUi-IArms.  nftorwnrdslUcco vc 
-     suvccssrni:  pod.     funis,  pro.;  arms    veryslo 
ver.;  breech  ex.;     slipped  by  bead;   septic 
fillet  ou  feet.  condition  of  pa-   mla. 


Weight 
of 
Child 

pounds 


Bitemporal,  3  inches . 


Bipurietai,  4i    inches ;    bi- 
tempoiiii,  3i  inches. 


3f;  bimnstoid,  2];  bitem- 
poral, 3j ;  bimolar,  31  in. 


Head  51easuremenls  of 


[Ictween     depressions,     3 
inches ;    behind    depres- 
sion, 3i  inches, 
lipai'ietal.  4    inches;    bi- 
terapornl,  31  inches. 


Ditempontl,  3  Inches.. 


tACTUllES   OF  THE  SKULL. 


Cause  of  Fracture 


Pressure   of  brow  \ 


Pressure  of  band  upon  soft 


bones  of  head. 


thro,  abdomen  up. 


on  hcadat'ainstpr 
force  in  extract,  li 


n-e  through  abdomen 


Pi-essure  of  forceps  blade 
and  promontory. 


Foetal     bones 


noted  before  opoiati 
Expression  throu^'b  j 
men     of     head     against 

Dnigging  of  head  tbrougb 

Expression  of  bead  througl 
abdomen    against    prnm- 

Apparently  pressure  of  for- 

Apparently      pressure     ol 


Fronto  -  parietal  region 
shaft  of  right  humerus. 

Left  parietal,  3  by  3  inches 
but  not  deep, 

3  in.  below  sagittal  suture 
by  upper  anterior  bordei 
of  temporal  bone. 

Right  temporal  region  (?).. 

Rupture  of  coronal  suture 


Left  parietal  anteriorly ; 
ight  side  between  parie- 
11  &  temporal  dei)i'ess!on 


parietal  bones. 

Parietal  region;  right  side. 
3byiby2in.;  shaft  r' 

[lirht''"fvnnto-parietJil 
giun,  Ibylbyj  inch. 

tiglit  frontal  region  ( 
eye,  Ibylbyl  inch. 


throii^Ii     abdo-  Left  parietal Delayed  rcspimti 

g  and  cceliyn 


facial  paralysis  from  1 


Delayed  respiration ;  dc 
pression  on  fifth  daj-. 

Delayed  respiration  10  min, 
cut  in  temporal  rcgioi 
just  above  ear  down  t 

Delayed  respiration :  ceph- 
alhii'mntoma ;     pnlsntmL' 

tjoth  sides  an 


h  freces. 
Cold  to  head  . . 


■eathed  only  a  few  times. 

Delayed  vospimtion ;  facial 
paralysis;  convulsions. 

'anilvsis     llexnr    nuiseles 
lefr,  arm.  apparently  due 


Convulsions  (?).. 


Immediate  Tr 


None  for  skull 

Fmcture  not  noted  t 


rtiflcial  respiration. 


Cupping(?) 

iVrtitlcial  respiration . 


Inimedi- 

snlt  to" 
Child. 


Good.. 


Death... 
Death,  2d 
Good.... 


-Two  sncceedioff  ohildreu  killed 


Soft;  premature 


.  Depro9slo__  __ 
mained  1  year 
Inter;  arm  O.  K. 


FRACTURE  OF  JAW. 
niction  on  jaw  in  deliveryLl 


1  of  2d  a 
'  shoulders  In  e 


Right  clavicle ;  ( 
Both    clavicles; 


bothlBieeding     from      mouth  ;| 

crepitus;  deformity;  ab- 

]    normal  mobility.  | 

Crepitus :    deformity; 
layed  respiration. 

Crepitus ;  deformity  . . . 


ii|    [Small ITraction 


leg;  upper  i;  ecchy-ICrepitus ;  deformity. 


ihTftai 


.  ISpIints  and  temp,  dressing  ;|Good ....  [Normal No 

long  splint  from  sacrum  to 
I  heel  and  perineum  to  heel.  I  I  I 


□buia  from  both  epiphj-- 


bral  symptoms, 
le  pression  dlsap- 

Dcp  ression  disap- 
peared iu  1  month. 

Wound    infected 
fith  day, 

II  30th  day ;"  iiopaV- 


.  Tnmoi-a    disappeared 
onSOf    • 


I  day  fjithor  toolc  baby  out  of 
^nobothoapit  1  1  isto  j    egi 

ulsloiis  coul  1  bo  b      gilt  on 


By  pressuro  on  the 
Autopsy. 


Depression  disnp- 
schartred  inth  <lay. 


Autopsy ;  Fig.  3,  p.  L'UO. 
Fig.  i.  p.  200. 
,  year  later 


i  left. 


.  Now  depression  remains,  JWyi 
since  delivery;  man  reini 
"     "   ■  :ht  pfiv  "  ■ 


I  Operation  to  relievo  depii?sslon 
'     and  doformity  ;  found  cyst  be- 
neath, on  opening  which  child 
went  into  collapse  and  died. 


s  T.UI  day  goiid  union;  i 
,  No  further  report. 


shortening  (?). 
.1  Autopsy. 


II  solid ;  function  good; 


Fig.  1.— C.  N.  26. 


Fig.  2.— C.  N.  26.     Tracing  Taken  at  Level  Marked  (1)  in  Fig.  1. 


Fig.  3.— C.  N.  255,  Indoor  History. 


Fig.  4.— C.  N.  378,  Indoor  History. 


FRACTURES    IX   THE    NEW    BORN.  293 

inent,  these  frontal  depressions  are  less  often  overlooked  than  the  others. 
They  are  usually  caused  by  pressure  of  forceps  applied  in  the  pelvic  curve 
of  the  mother  to  the  head  of  the  foetus  when  above  the  In-im  of  the  pelvis. 
Even  in  the  hands  of  good  operators  this  accident  may  occur.  The  cephalic 
application  of  high  forceps,  if  otherwise  safe,  would  avoid  it. 

Occipital  clepressions  occur  in  the  same  wa}^  as  do  frontal,  from  pressure 
of  "high  forceps  operations."  Owing  to  the  proximity  of  the  medulla, 
these  fractures  would  more  surely  cause  death  than  any  of  the  other  forms. 
If  the  child  lives,  the  depression  usually  corrects  itself. 

Whether  the  base  of  the  skull  in  a  child  living  after  delivery  is  ever 
fractured  is  still  a  mooted  question.  Cases  of  facial  23aralysis  are  usually 
due  to  pressure  of  the  forceps  blade  on  the  branches  of  the  facial  (seventh) 
nerve  where  those  branches  cross  the  mandible.  Such  cases  recover  in  a 
short  time.  There  are,  however,  one  or  two  cases  reported  (Jolly)  of  per- 
manent unilateral  facial  paralysis,  infantile  in  origin,  accompanied  by  unilat- 
eral deafness  on  the  same  side,  also  permanent,  an  occurrence  strongly 
suggestive  of  fracture  through  the  temporal  bone. 

Rupture  of  a  suture  line,  as  in  C.  N.  5,854,  of  course  has  the  same 
dangers  to  the  child  as  a  fracture  of  the  skull,  with  all  the  additional 
danger  of  meningocele. 

BiBLIOGKAPHY. 

Jolly:  British  Medico-Chirurgical  Journal,  1889,  June. 

Stephen:  Medical  JN'ews,  January,  1889. 

Dauchez:  British  Medical  Journal,  October  31,  1891. 

Hewett:  Holmes's  System  of  Surgery  (Am.  ed.),  vol.  i.,  p.  627. 

Prognosis. 

Rosinski  reports  44  cases,  with  16  recoveries;  Shroeder,  65  cases,  with 
33  recoveries  (22  born  dead,  and  10  dying  within  a  few  days).  Among  the 
17  cases  seen  by  the  writer,  there  are  10  recoveries. 

That  the  depression  is  not  always  injurious,  witness  the  now  thirty -years' 
old,  deep,  frontal  depression  of  D.  E.,  an  instructor  in  a  New  York  college, 
and  C.  ]Sr.  26,  at  five  years  old,  a  very  bright  child.  The  new-born  corti- 
cal brain  cells  are  not  developed  (Edinger,  His,  etc.)  save  in  the  motor 
area,  therefore  the  delicacy,  noted  by  Jacobi,  of  the  blood-vessels  in  child- 
hood is  not  so  great  a  danger  as  among  similar  injuries  to  adults.  In 
giving  a  prognosis,  one  must  be  guided  by  the  locality  of  the  fracture, 
the  accompaniment  of  injuries  to  the  skin,  the  depth  and  area  of  the 
depression,  the  time  taken  in  delivery,  the  time  needed  to  resuscitate,  the 
symptoms  present  after  delivery  or  developing  later.  The  after  history  of 
these  cases  is  so  often  lost  that  an  accurate  study  of  their  course  is  only 
made  by  the  collected  observations  of  different  men,  not  always  agreeing 
as  to  signs  noted. 

Complications. 

All  the  dangers  of  fracture  of  the  skull  depend  upon  the  complications, 
generally  haemorrhage,  as  the  depression  itself  is  usually  not  sufficient  to 


294  REPORT   OF   THE   SOCIETY    OF   THE    LYIXG-IN    HOSPITAL. 

impinge  dangerously  uj^on  cranial  content^^.  If  the  fracture  occurs  from 
the  use  of  instruments,  the  haemorrhage  is  usually  outside  the  dura  mater,  is 
slight  in  extent,  and  of  little  consequence;  if,  however,  there  is  much  over- 
lapping of  the  cranial  l)ones,  or  a  very  deep  depression,  there  may  be  a 
hirire-sized  ha?matoma  in  the  cortical  substance  sufficient  to  cause  death. 
iSuch  a  hanuatoma,  l)eneath  frontal  de})ressions,  indenting  u})on  no  vital 
centres,  may,  according  to  Dr.  ]\r.  Allen  Starr,  remain  as  a  cyst.  (See  case 
fi-om  Recoitls  of  New  York  Hospital,  lettered  ''  f.")  Operations  upon  such 
de])ressions  and  cysts  are  very  dangerous,  from  change  in  intracranial 
pressure  on  removing  the  cyst  fluid ;  an  indication,  therefore,  for  early 
0}3e ration,  if  any  is  to  be  undertaken. 

The  fractures  of  the  skull  due  to  breech  deliveries  and  podalic  version 
are  usuallv  accompanied  by  much  cerebral  congestion,  and,  therefore,  often 
by  hcemorrhage.  The  spastic  paraplegias,  idiocy,  microcephalus,  epilepsy, 
cerebral  palsies,  and  insanity,  as  the  result  of  difficult  deliveries,  and  due  to 
cerebral  injuries,  are  noted  in  only  one  case  of  the  lt»,238  here  considered. 
A  child  (C.  X.  3,394)  of  healthy  parents  had  an  arm  fractured  in  delivery, 
but  no  cerebral  injury  was  noted  at  Ijirtli.  One  year  later  this  child  is  a 
microcejihalic  idiot. 

Infection  from  scalp  wound  and  compound  skull  fractures,  of  course, 
predispose  to  meningitis,  encephalitis,  epiphysitis,  septicaemia,  or  pj^semia. 

Etiology. 

A  jutting  promontory,  or  exostosis  jutting  from  the  j^elvic  wall,  with 
breech  extraction,  seems  to  be  the  cause  of  skull  fractures  more  common 
than  anything,  unless  it  be  the  perforator. 

Pressure  through  the  abdominal  wall  upon  the  after-coming  head,  in 
difficult  In-eech  extractions,  seems  the  next  most  common  cause;  even  more 
fre<|uent  than  the  hasty  or  injudicious  i:>ulling  upon  forceps  applied  at  the 
superior  strait  Ijefore  moulding  has  time  to  take  ])lace.  These  and  the  for- 
cible a])proximation  of  the  forceps  blades  (an  uncommon  cause,  owing  to 
the  wide  cephalic  curve  of  an  ordinary  instrument)  of  course  can  be 
averted. 

Pressure  of  tlio  liead  against  a  displaced  fcx'tal  limlj  can  only  occur  in 
much  defornx.'d  pelves — a  fi'acturc  from  such  cause  is  reported;  also  a  case 
where  a  skull  was  fractured  against  a  jutting  promontor}''  by  uterine  force 
alone  (Tuckei-).  Hamilton  mentions  sucli  a  case.  Matthews  Duncan 
describes  a  <l<'pression  ma<le  by  ])ressure  of  the  accouclieui"'s  fin<i'er  in 
att<impting  t<j  produce  rotation.  In  |ii-eci])itate  lal)ors  infant  skull  frac- 
tures are  rejioi'tcd  fi-om  the  fall  of  the  child  against  the  floor  or  the  edge  of 
tlie  vessel  over  which  the  mother  was  standing'.  In  an  effort  to  )'esuscitate 
the  child  by  Schultze's  method,  the  writci'  has  seen  a  cliild  sli|)  from  the 
r)|M'rator''s  hands,  and  in  the  fall  sustain  a  fracture  of  the  skull.  Lowen 
and  .Joullin  have  demonstrated  that  a  coiM|»rcssiii^-  force  of  loo  pounds 
applied  for  two  or  three  minutes  continuously  will  fracture  the  skull  of  a 
normal  ffjetus. 


FRACTURES   IN   THE   NEW   BORN.  295 


Symptoms. 


The  deformities  of  the  skull  are  apparent  at  delivery  if  haematomata 
do  not  conceal  thera.  Crejoitation  and  abnormal  mobility  cannot  be  made 
out.  Muscular  twitcliings  or  convulsions  starting  unilaterally,  unilateral 
paralysis,  blindness  or  deafness,  coma,  subnormal  temperature,  delayed 
respiration,  irritability,  sleeplessness,  sudden  death — all  are  indications  of 
cerebral  haemorrhage,  which  may  or  may  not  be  accompanied  by  fractures. 

Diagnosis. 

From  cephalhaematomata,  either  early,  when  the  depression  may  not  be 
noticed,  or  late,  when  the  edge  of  the  organized  clot  may  be  mistaken  for 
depression.  From  overlapping  of  cranial  bones,  particularly  abnormal  or 
'  <  Wormian  ' '  bones. 

Teeatment. 

Dr.  Irving  W.  Smith,  Dr.  McKennan,  Dr.  Jennings,  each  elevated 
such  depressions  as  we  have  noted,  with  recoveries  in  all  the  cases.  If  the 
fracture  is  compound  (unfortunately  the  forceps  often  make  it),  or  if  the 
depression  causes  symptoms  of  compression — subnormal  temperature,  coma, 
respiratory  delay — as  in  Dr.  McKennan's  case,  there  would  be  no  question 
as  to  the  propriety  of  elevating  the  depressed  bone.  Frontal  depressions 
are  commonly  permanent,  therefore  this  would  particularly  apply  in  their 
case.  Parietal  and  occipital  depressions  usually  correct  themselves.  How- 
ever, in  a  deep  parietal  depression  recently  seen  by  the  writer,  after  breech 
delivery  through  a  narrow  conjugate,  when  respiration  could  not  be  excited 
after  twenty  minutes,  and  the  heart  was  becoming  slow,  it  seemed  as  if, 
had  elevation  been  practised,  the  child  might  have  been  made  to  breathe. 

Jennings  summarizes  active  treatment  thus:  first,  the  use  of  cups 
(among  older  writers  condemned  for  the  intracranial  haemorrhages  the  cups 
apparently  caused ;  unsuccessful,  also,  in  a  trial  of  their  use  seen  by  the 
writer) ;  second,  elevation,  itself  not  a  dangerous  proceeding,  save  for 
possible  infection.  Jennings  advises  replacement  of  any  pieces  removed. 
He  urges  immediate  action  if  symptoms  are  present,  even  if  the  operation 
has  to  be  done  with  a  boiled  pocket-knife.  Later  interference  he  suggests 
if  the  depression  be  more  marked  at  the  end  of  the  second  week.  Because 
loss  in  weight  will  of  itself  increase  any  depression  in  an  infant's  skull, 
and  an  organized  clot  (Dr.  M.  Allen  Starr)  might  have  already  assumed 
the  character  of  a  cyst,  such  interference  should  be  undertaken  at  birth  or 
within  a  day  or  two. 

BiBLIOGEAPHT. 

Eosinski:  Zeitschrift  filr  Geburt  u.  Gynak.,  1893,  xxvi.,  225. 
Fritsch  und  Shroeder:    Klinik  der  Geburtshiilflichen  operat.   auf,,  p. 
305. 

Siche:  Centralblatt  fiir  Gynak.,  189tt,  xxxv.,  p.  856. 


29G  REPORT   OF   THK   SOCIETY    OF   THE    LYING-IM    HOSPITAL. 

Fen.vick:  International  Clinic,  1S93,  p.  24S. 
:  Charlotte  (X.  C.)  Medical  Jour.,  1S93,  17. 

Xairel:  International  ^leil.  Mag.,  1S92,  G70. 

lieynultls:  X.  Y.  Med.  Jour.  Gyn.  and  Obs.,  1S92,  907. 

Porak:  Kev.  Obs.  et  Gyn.,  1S93,  ix.,  119. 

Jennings:  X.  Y.  Med.  Jour..  Mar.  10,  1S94. 

Tucker:  Anns.  Gyniec.  and  Obs.  Jour.,  Sep.,  1890,  p.  279. 

Bull.  Soc.  de  Chirurg.,  Paris,  1857,  p.  278. 

Bull.  Soc.  de  Chirurg.,  Paris,  1802,  2d,  p.  159. 

Larkin:   Lancet,  London,  1872,  vol.  i.,  p.  490. 

Arnold:   Boston  ^Med.  and  Sur.  Jour.,  vol.  Ixxxvi.,  352. 

Mercier:  Brit.  Med.  Jour.,  1881,  vol.  1.,  p.  847. 

Sinkler:  Med.  and  Surg.  Keport,  1887,  p.  675. 

Lusk:  :Med.  anil  Surg.  Beport,  1887,  p.  673. 

West:  Trans,  of  London  Med.  Chirurg.  Soc,  1845,  p.  397. 

]'>arin:  Bull,  de  la  Soc.  Anat.,  vol.  xlviii.,  p.  426. 

Borges  (G.  II.  L.):  Ueber  Schiidelrisse  an  einen  neugeboren  Madchen 
und  den  Entstehung,  8vo,  Mlinster,  1833. 

Hirt:  De  cranii  neonatorum  fissuris  ex  partu  natural!  cum  novo  eorum 
exampla.     4to,  Lipsiae,  1815,  i. 

Ilorstmann  (H.):  De  fissures  in  cranio  neonatorum  congenitis,    8vo, 
Marburgi  Cattorum,  1854. 

Jayet:  Des  fractures  des  os  du  crane  chez  les  enfants  nouveau,  4to, 
Paris,'  1858. 

Jouslain  (A.):  Des  enfoncements  et  fractures  du  crane  produits  chez  le 
nouveau-ne  pendant  I'accouchement,  4to,  Paris,  1805. 

De  Xinbeck:    Des  fractures  et  des   enfoncements  du  crane  du  foetus 
pendant  raccouchement,  4to,  Strasburg,  1863. 

Ileali  (G.):  Ueber  die  Behandhmg  du  angeborenen  Schiidel  und  Riick- 
gnitsbriiche,  8vo,  Zurich,  1874. 

Reis  (G.  R.):    De  capitis  neonatorum  laesionibus  ex  partu  cum  novo 
earum  examplo,  8vo,  Gryphiswaldia?,  1860. 

Rose  (F.):  Ueber  die  Schadelverletzungen  die  Xeugeborenen  in  gerichts- 
iirzlichen  Beziehung,  Svo,  Menden,  1880. 

Schuralz  (C,  J.):  De  laesionibus  ossium  cranii  inter  partum  factis,  Svo, 
Jenie,  isoo. 

Siegel  (F.):  De  cranii  neonatorum  fracturis  partu  natural!  effectis,  Svo, 
Dorpat,  1S34. 

Abbot:  JJoston  M.  and  S.  J.,  1>;72,  Ixxxvi.,  351. 

Adanikiewicz:  Vrtljschr.  f.  gevvchtl.  in  off.  Med.  Berlin,  1864,  n.  F.  I. 
211. 

Angobonn:   iil.  f.  gerichtl.  Anthrop,  Ansl)ach,  1854,  v.  4,  lift.  63. 

Ba.shain:  London,  M.  and  S.  J.,  ls35-3(),  viii.,  187. 

Becker:  Ztschft.  f.  d.  Staatsarznk.,  Erlang.,  1833,  xxvi.,  245. 


Fig.  5.— C.  N.  11.016.  A  Pix  ix  Ba>-dage,  and  Thumb 
OF  Nurse  Holding  Limb  while  Exposed  to  Eoxtgek 
Rays  are  Shown. 


fractures  in  the  new  born.  297 

Separation  of  EpiphysiSo 

The  radiograph  (Fig.  5)  here  given  was  taken  of  a  case  (C.  IST.  11,010) 
to  be  fully  reported  in  next  series.  It  is  supposed  to  be  an  epiphj^seal 
separation.  The  epiphysis  is  apparently  so  cartilaginous  that  Rontgen 
photogra})hy  penetrates  it  the  same  as  through  other  soft  parts. 

Gurlt,  1S62,  reports  three  cases  of  separation  of  epiphysis  at  birth, 
diagnosis  verified  at  autopsy;  one  by  traction  upon  feet,  two  by  traction 
upon  arm  or  axilla.  Hamilton  mentions  a  case,  while  Bruns,  in  a  series  of 
eighty-seven,  mentions  ten  that  occurred  at  birth.  According  to  Gurlt,  it 
is  difficult  to  separate  an  epiphysis  by  direct  traction,  l)ut  very  easy  on 
forced  hyperextension  or  hyperflexion  of  joints,  more  particularly  the 
ankle,  knee,  elbow,  and  shoulder.  C.  'N.  225  (indoor  historj^)  here 
recorded,  verified  at  autopsy,  showed  separation  of  the  lower  epiphyses 
of  both  tibite,  due  to  the  use  of  a  fillet  around  the  ankles,  the  feet  hjq^er- 
extended  in  a  difficult  version. 

If  the  child  lives,  early  ossification  of  such  separated  epiphysis  may 
take  place  and  growth  of  that  bone  cease.  The  limb  will  then  be  short- 
ened. Such  a  case  is  said  to  be  the  arm  of  the  present  Emperor  of 
Germany.  Arrest  of  growth  from  this  cause  must  be  rare,  as  stunted 
growth  may  be  induced  by  fracture  of  the  shaft  when  chronic  inflamma- 
tion of  the  bone  has  followed.  Bruns  has  pointed  out  that  the  line  of 
separation  is  more  apt  to  be  through  the  partially  ossified  portion  of  the 
epiphysis  (the  most  brittle),  and  the  chondrogenetic,  or  growing  portion,  to 
remain  uninjured. 

BiBLIOGEAPHY. 

GurJ.t:  quoted  above. 

Helferich:  Fractures  and  Laxations,  1894, 

Manquat:  Sur  les  decoUements  epiphysaires  traumatiques,  These  de 
Paris,  1877. 

Bruns:  Langenbeck's  Archiv.,  vol.  xxviii.,  p.  240,  1882. 

Partridge:  K.  Y.  Med.  Jour.,  March  22,  1890. 

Barr:  Archives  de  tocologie  de  gynecologic,  Paris,  March,  1895. 

Kuestner:  quoted  above. 

Tillmans:  quoted  above. 

Bitol:   J.  de  Med.  de  Bordeaux,  1859,  2  s.,  iv.,  5-19. 

Godfrey  (H.  T.):  Chicago  M.  Rev.,  1882,  v.,  iii. 

Ghillini:  Archiv.  f.  Klin.  Chir.  Berlin,  1893,  xlvi.,  8M. 

Tubbey:  Ann.  Surg.,  Phila.,  1894,  xLx.,  289-325. 

Stunock:  Edinburgh,  Hosp.  Report,  1894,  598-608  (after  results). 

Savage:  Med.  Rec,  ]^.  Y.,  1895,  xlvii.,  690. 

Missenbach:  Med.  Rec,  K.  Y.,  1895,  xlviii.,  475. 

Milliken:  Arch.  Pediatrics,  K.  Y.,  1894,  xii.,  611. 

Simpson  (A.  R.):  Obst.  Jour.  W.  Brit.,  London,  1880,  viii.,  553. 


•29S  REPORT   OF  THE   SOCIETV   OF   THE    LYING-IX   HOSPITAL. 


Fractuke  of  the  Jaav. 

AVinckel  alludes  (citing  a  case  of  his  own)  to  this  clanger  in  the  old 
Sniellie  -Veit  method  of  deliveiy  with  finger  in  the  mouth  of  the  after 
coming  head  of  the  ftvtus,  as  in  the  case  here  reported.  Dr.  A.  B.  Davis, 
of  this  Hospital,  in  two  breech  cases  Avhere  the  children  were  known  to 
lie  dead,  found  it  impossible  by  this  method  to  fracture  the  mandible,  and 
the  writer  made  the  same  observation  in  a  tliird  case.  Parvin  says  a  force 
of  fifty  pounds,  direct  traction,  Avill  break  the  jaw.  Dr.  Lusk  speaks  of 
having  fractureil  a  jaw  in  an  effort  to  convert  a  brow  into  a  face  presenta- 
tion. 

Heath  points  out  that  most  of  these  cases  are  fortunately  still-born, 
and  escape  deformities  in  later  life.  A  case  at  8t.  Mary's  Free  Hospital 
for  Children,  operated  u})on  by  Dr.  Poore,  the  writer  assisting,  December. 
1895,  illustrates  the  possibilities.  A  boy,  eleven  years  old,  with  atrophy 
of  the  mandible,  ankylosis  of  the  mandibular  joint,  unilateral  bony  coales- 
cence of  condyle  and  zygoma,  existing  since  infancy,  and  fed  by  suction 
through  gap  between  teeth  where  maxillary  overlapped  mandibular  inci- 
sors; with  no  scars,  no  trouble  with  teeth,  no  a]ipearance  of  tubercular 
infection.  The  parents  were  dead,  and  the  history  obscure.  The  proba- 
l)ility  seemed  that  a  breech  delivery  had  been  conijileted  by  Smellie  -Veit 
method,  and  fractures  (perhaps  compound,  with  ])eriostitis,  causing  dimin- 
ished growth  of  the  mandiljle)  had  taken  place.  Excision  gave  him  good 
movement  of  the  })oorly  developed  jaw  he  had  left.  Paralysis  of  the 
inferior  dental  branch  of  the  fifth  nerve  might  be  a  complication,  as  might 
atrojiliv  of  the  jaw  and  unecjual  eruption  of  the  teeth,  or  the  occurrence  of 
dentigerous  cysts. 

Such  a  fracture  could  be  held  in  position  by  a  starch  bandage  around 
tlie  head  or  with  a  dental  ])late,  and  the  child  fed  by  gavage  through  the 
nose. 

P>II{I,IOGRAl'IIV. 

Heath:  Injuries  and  Diseases  of  the  Jaws,  London,  1884. 
Winckel:  (Edgar's  Translation)  Text-Book  of  Obstetrics,  Philadelphia, 
1890,  p.  689. 

Duncan,  Matthews:  qucjted  above  (Champetier). 

Fractures  of  the  Vertebra. 

These  cases,  save  in  one  instance,  liave  not  been  included  in  the  list  of 
fififtnres,  as  de{'a))itati(»n  divides  so  much  beside  bone.  In  C.  N.  9.'}*.), 
pi-emature  twins  iiad  l)oth  heads  pulled  off  at  deHvery,  and  the  heads  after- 
ward extracted  with  difficulty.  C.  N.  7,018  was  a  case  of  decapitation  for 
an  impacted  shoulcU'r  ])osition.  In  C.  X.  8,74.'.  Ihe  he;i(l  was  ])ulle(1  off  l)y 
Uh)  zealous  traction  upon  an  impacted  breech. 

Several  cases  have  been  rej)orted  due  to  Smellie- Veit  mode  of  delivering 
the  after-coming  he;i(l  when  the  body  <»!"  \\\<-  cliild  h;is  heen  bent  backward 


FRACTURES    IN   THE    NEW    BORN.  299 

ov^er  the  symphysis  of  the  mother  to  save  a  perineum.  Because  the  ante- 
rior spinal  ligament,  however,  is  weaker  than  other  ligaments,  it  is  more 
apt  to  give  way  than  the  bone.  The  awkward  use  of  Schultz's  method  of 
resuscitation  might  fracture  vertebra?,  although  no  case  has  been  reported. 

If  the  child  survived,  fractures  of  the  atlas  might  cause  hypoglossal 
paralysis.     (Erb.) 

Bibliography. 

Winckel:  quoted  above. 

Montgomery :  Observations  on  Obstetrics. 

Erb:  In  Zieinsen,  1876,  vol.  xi.,  p.  254. 

Fracture  of  the  Ribs. 

No  case  in  this  series. 

One  fracture  reported  by  Gebhard,  where  a  rib  penetrated  the  lung 
after  Schultz's  method  of  resuscitation  had  been  tried.  Death  of  the  child 
resulted  from  haematothorax.  Whether  the  method  of  resuscitation  or 
the  delivery  caused  the  fractures  is  not  stated. 

Bibliography. 

Gebhard:  Am.  Jour,  of  Med.  Sci.,  Phila.,  February,  1895. 
Smith:  Obst.  J.  W.  Brit.  (Amer.  Supplem.),  Phila.,  1877,  v.  6. 

Fracture  of  Sternum. 

No  case  in  this  series.  Eauber  has  shown  that  in  children  the  sternum 
may  be  forced  back  to  the  spinal  column  without  fracture. 

Andree:  J.  f.  Geburtsh.,  Frankfort  a  Main,  1828,  viii.,  101-107. 
Tillmanns :  quoted  above. 

Fractures  of  the  Clavicle. 

These  fractures  probably  occur  much  more  often  than  is  generally 
stated,  because  the  injury  causes  an  infant  very  little  inconvenience,  and 
more  cases  of  Erb's  paralysis  than  of  fractured  clavicles  are  reported. 

Etiology. 

In  the  Smellie-Yeit  method  of  delivering  the  after-coming  head,  or  any 
method  of  breech  extraction,  where  two  fingers  are  hooked  over  the 
shoulders  as  point  of  traction,  not  only  is  there  a  possibility  of  tearing 
away  the  cervical  nerves  from  the  roots,  but  of  bending  the  clavicle 
against  the  upper  or  outer  cord  of  the  brachial  plexus,  and  even  of  fractur- 
ing the  clavicle,  as  in  the  cases  here  recorded.  Cases  are  reported  due  to 
Schultz's  method  of  resuscitation.  The  force  is  one  of  torsion  and  bend- 
ing, a  combination  requiring  the  least  power  necessary  to  accomplish  a 
fracture.     Winckel  mentions  a  case  due  to  the  arrest  of  a  shoulder  behind 


300  REPOHT   OF   THE   SUCIETV    OF   THE    LYING-IX    HOSFFrAL. 

tlie  svmpliysis  after  a  forceps  delivei'v  o^  a  vertex.  A  similar  occurrence, 
but  duo  to  uterine  force  aloiio.  w  Iumi  in  a  vortex  presentation  the  shoulder 
caught  behind  the  symphysis,  has  boon  related  to  the  writer  by  Dr.  S.  W. 
Lambert. 

Complications. 

Erb's  or  brachial  paralysis  may  coexist.  It  is  usually  not  due  to  the 
fracture,  but  to  the  same  force  which  produced  fracture.  Kupture  of  the 
lung  by  the  shar[)  end  of  a  fragment  is  recorded  by  Schultz  himself,  in 
describing  his  mode  of  artificial  resuscitation.  Heyderich  mentions  a  simi- 
lar accident.  Puncture  of  the  brachial  cord  is  reported  by  Dr.  Weir 
^litoholl,  and  of  course  it  is  possible  that  the  fractured  end  might  enter  a 
subclavial  vein  or  artery. 

Dr.  Royal  Whitman  has  recently  pointed  out  that  the  shortening  of  the 
cla^•icle,  which  repair  in  most  cases  brings  about,  might  shorten  the  support 
of  the  sca])ula  sufficiently  to  promote  a  tendency  to  rotaro-lateral  curva- 
ture of  the  spine. 

Symptoms. 

Crepitus  is  usually  felt  in  delivery  at  the  time  of  fracture,  a  faint  audible 
snap.  Tliis  is  sometimes  misleading,  because  in  a  case  whore  the  snap  was 
heard,  the  writer,  after  careful  examination,  could  make  out  no  fracture. 
Deformity  is  as  marked  as  in  an  adult,  ])articularl_y  when  the  fracture  is 
comi)leto.  Tenderness,  apparentlj^  is  always  present.  Row  significant  it 
is  in  childhood  is  still  questioned.  Pseudo-paralysis  may  be  due  to  this 
same  tenderness,  but  may  be  confused  with  a  true  brachial  paralysis.  A 
false  point  of  motion,  owing  to  the  lax  joints  of  infants,  is  difficult  to 
make  out. 

Treatment. 

If  the  infant  were  a  girl,  and  there  Avere  any  doubt  about  future 
deformity,  the  child  should  be  stra])i)ed  to  a  board  or  a  Bradford  frame, 
with  the  shoulders  back.  Otherwise  Sayre's  strapping,  as  used  for  adults, 
and  a]»|»liod  for  ton  days,  is  sufficient.  If  not  treated,  after  two  or  thi'ee 
months  a  careful  examination  will  usually  fail  to  reveal  deformity. 

Bibliography. 
AVoir  Mitclicll:  Injury  to  Xerves. 
(iibson:   Principles  of  Surgery,  Oth  ed.,  vol.  i.,  ]).  27. 
Heydericli:  Glasgow  Med.  Jour.,  July,  1890. 
Sfhnltz:  Auk  Jour,  of  Med.  Science,  July,  ls!»4. 
llodgon:  cjuoted  by  Pai'vin. 
Knight:  (juoted  by  Parvin. 

FkACTUKES    of    ScAl'ULA. 

There  are  none  in  this  seri(!s. 

AVagner  reports  one  case  with  a  somcwli.-ii  olisciirc  liistoiy  in  the  Uni- 
versity M<-d.  \\:\<^..  I'liil;idr||i!ii;i.  .\|.iil.  ls;)4. 


XiaUursciiBy.. 
lilrths. 

'lovlniis  In- 

'I-CVIOUB    111. 

uusy  Inborai 
f  r.  I'liiuiw  In  privnto  pnic. 

°l1?n**/  ^'';  ^''»■'t<«' '"  pi-lvato  pnic- 
«L-im  """'"  iU'loi'    fmctm-es   ol' 


tlnUve;ltmui 

Iscarrlugt't 


rovioiifl  la- 


.Montb 

of 

Gestation, 


Jt  "It: lies. 


L.  Scup.  P. 
L.  S.  A. 


R.  U.  A. 


H.  O.  A. 


L.  S.  P. 
L.  S.  A. 

Vertfx    (?) 
U.  O.  A. 

It.  S.  A. 

L.  M.  A. 

L.Si-ii|..A. 

L.  ( ).  P. 

U.  O.  P. 


formity  (V) 
rutting  nroit 


Jiisto-minor  pelvis 
nrnlapscd  futijs. 


prolapsed  funis. 
Pelvis  small  (?) 

Pelvis  small;    pro- 


AlbuminurJn :  de- 
formed pelvis. 

Mnlpositlon  fcetus.. 
:)i3pliiccmeiit  ol 
Loeldnifof  twins.., 


.Tiisto-minor  pelvis. 
Pioliipsed  funis  unc] 

PnilHpscd  finiis;  de- 


Breccb  extraction. 


Difficulties  of  Open 


Arms  locked   behind 

Great     force      u 
i extended. 

Arras  extended.. 


(podiiHc  version  oi 
iiiherclilld). 
Breeeb  extraction. 


r\rms  locked  bebind 
Left  arm  extended . 


tended.  torn;   final 

CO very. 
■Vrms  extended Good 


Length 
Child. 


Cbild's    heart 


Arms  extended.. 


Mnlpositlon  of  child  Poi 


Albuminuria:    Jut- 
ting promontory 


Aecoucbflm'tforce; 
nodnlio  version 
ui-eech  extraction. 


Itef  used  trc 
ttfteropcnition; 

SI"'":"" 


FKACTUKES    OF   HUMERUS. 


f  Cbild.  Cause  of  Fracture. 


Male  .... 
Female. . 


Female.. 
Male  .... 


Male  . . .  - 
Female.. 


.  Attempts     to     die- 
lodge    rigbt     "" 

Attempts  to  s 


Position  of  Frac- 

Kight  sbaft. 
per  S. 

Right  sbaft., . 

-  Left  abaft. .  -  . 
.  Left  middle  i  . 


.  Small  splints ;  soft  bandage. 


.  Crepitus; 


held    rigid ;  J 


.  Extraction  of   lii-st  I 
xtcnded  r 

xtraction 
xtendcd  a 

.  Great  force  used  in  I 

tended  arm. 
Unknown 

.  Extraction  of  i 

across  back 

cbild. 
.  Extraction  of   i 

purposely  aci 

baclt  of  cbild. 
.  Extraction   of   i 
ross  back 

1  caught  against 


.  Right  shaft. 

.  Right  e  pi  physist?) 
probably  not. 

n  Rightshaft;  "pai-- 
V   tial  dislocation  o" 

shoulder." 
n  Right  shaft 


.  Early  qss 

skull. 
.  Brittled  ( 

Normal , 


t  parts  greatly  swollen. 

-  Facial  paralysis  from  forceps; . 
"    temperature,  90";     pi     "' 
paralysis  left  side  (?) 

)  Fracture  of  skull  as  wt 


■s;  pasteboard  splints. 
I  across  chest;  soft  band-  . 


delivered  with 
extracted  with 

extracted  with 
c  through  1 
peh-is. 

tended  arm. 
.  Extraction    of  i 
.  Extraction  of  1 


Left  upper  } 

Left  (?)  middles. 
Left  upper  J 

Leftmiddlej... 

Right   upper 
middle  j. 

Left  shaft.... 
Left  lower  i.. 


Delayed  respii'ation 

deformity ;  a 
„  id ;  crepitus  mar 
noted  untUr)tli  day 
No  crepitus;  mobiil 
direction  only;  ds 
"green-stick." 
Arm  held  rigid 

.  Crepitus 

.  Crepitus;  mobility. 


ages;  pasteboard  splin 

Starch  bandage  around  chest, 

to  which  arm  fastened  with 

stareb  bandage. 

,  Starch  bandage 

:1  Soft  bandage ;  arm  to  si 

c Smalt    wood    splints; 
bandages. 

.Splints;   soft  bandage; 

.Splints:  softbandngo; 

lostorcase  removed  on 

,  Plaster  case    around   h 
1  bound  to  case. 

.  Splints  for  two  days,  then  . 
plaster  case. 

Arm  across  chest;    splints; 
soft  bandages. 


temperature,  97° ;  S 


-  Notbrokenat  birtii 
but  noticed  5  day 


I  Right  upper  J. 

Right    upper 
i  epiphysis  (?) 

,  Left  upper  J  ... 


,  Normal  . 


delayed  respiration. 


Night  cry;  pseudo-itaralysi 
;repilus;  mobility. 


3  oround  thorax 


.  U    "     (?). 


n  swelled  and  plos- 


Large    callus; 


weniy-Qrstday  refractured; 
,wo   months   later  position 
md  lunctiou  good, 
iill  birth. 

.  Still  birth,  duo  to  delay  in 

.    mouths   lator  position 
and  function  good. 

no  year  later  child  wasmi- 
jroccphalic  idiot ;  no  paraly- 

.  Good. 

.  Good  Olio  month  at'tor. 

,  Said  to  bo  "O.K." 

sbortuning. 


t'-Hirco  days  later  po- 

ty-thrco  days  Inter  po- 
sition ami  function  good, 

luggcstcd,  but  refused. 


right." 


later 


,  Good, 

Still  birtli,  due  to  dldlcu 
,  Slight  deformity;  goud  I 

Twenty-live  days:  good, 
.  Still-born,  duo  to  delay  ii 


months  later   positim 
function   perfect;    m 


ad  been  delivered  by  midwife  two  days  pre' 


r  fractures  of  skull. 


Fig.  6.— C.  N.  12,027.     Fracture  of  Humerus. 


Fig. 


7 c.    N.    12,027.      Fkactuke    op     Humerus 

Seventeen   Days  after  Birth. 


fractrres  in  the  new  born.  303 

Fractures  of  the  Humerus. 

The  radiographs  (Figs.  6  and  7)  here  shown  of  C.  IST,  12,027,  to  be  reported 
in  next  series,  although  somewhat  dull,  indicate  the  ordinary  overlapping  of 
the  fragments.  These  pictures  are  opposed  to  Dr.  Reynolds'  assertion  that 
most  of  these  fractures  are  ' '  green  stick."  Only  one  in  this  series  of  twenty- 
six  cases  was  of  that  character.  The  second  picture  shows  the  callus  for- 
mation after  seventeen  days.     The  arm  is  firm,  and  externally  shows  no 

deformity. 

Etiology. 

In  this  list  it  will  be  noticed  that  in  all  but  four  citations  a  breech 
had  been  extracted,  either  breech  presenting  or  after  podalic  version.  One 
of  the  three  is  C.  N".  780,  delivered  by  midwife.  The  mechanism  is 
unknown.  C.  K.  5,723  should  not  be  counted  an  accident;  the  arm  caught 
behind  the  symphysis,  was  purposely  swept  across  the  back,  necessarily 
breaking  it,  because  the  operator  feared  to  delay  in  the  interest  of  the 
child's  life.  In  delivery  of  the  breech  this  is  the  danger  always  taught  to 
students,  the  inexcusable  sweeping  of  arms  behind  the  child's  back,  partic- 
ularly the  first  arm  to  be  delivered.  Ifearly  all  the  cases  in  the  present 
list  were  breech  extractions  in  which  the  arms  were  extended  above  the 
head.  In  narrowed  pelves,  under  conditions  when  rapid  delivery  seems 
essential  to  the  life  of  either  mother  or  child,  the  act  of  sweeping  a  child's 
arms  across  its  face  is  accomplished  with  great  force.  Pressure  is  exerted 
as  in  a  lever  of  the  first  class.  The  accoucheur's  finger  is  a  fulcrum,  with 
the  child's  forearm  and  lower  half  of  its  humerus  as  the  long  arm  of  the 
lever  against  the  whole  uterine  and  abdominal  pressure.  The  fixed  uj^per 
half  of  the  humerus  is  the  short  arm.  In  such  conditions  breech  extraction 
endangers  the  child's  arms.  C.  IS".  9,575  was  extracted  by  hooking  the 
finger  beneath  the  shoulder;  a  similar  fracture  of  Gurlt's  was  made  by  a 
blunt  hook  in  the  axilla ;  and  a  fillet  in  the  axilla  broke  an  arm  for  Char- 
pentier.     All  were  vertex  cases. 

In  Hamilton's  "Fractures"  Dr.  Stephen  Smith  quotes  a  case  of  Dr. 
Fanning,  when  in  a  vertex  presentation  the  arm  arrested  behind  the 
mother's  symphysis  was  broken  by  uterine  force  alone.  If  the  arms  are 
extended  beside  the  body  of  a  child  in  a  vertex  presentation,  while  the 
body  is  passing  out  of  the  vagina,  around  a  symphysis  which  impinges 
against  the  humerus,  it  is  possible  that  the  humerus  might  be  fractured  in 
the  same  way  that  Reynolds  has  shown  the  femur  may  be  broken.  The  lift- 
ing of  a  child  by  one  arm,  as  in  C.  ]S".  9,886,  has  long  been  known  as  a 
cause  of  shoulder  dislocation,  of  separation  of  the  epiphysis  of  the 
humerus  or  scapula,  or  of  fracture  of  the  shaft  of  the  humerus.  Sixteen 
of  these  twenty-six  children  were  males,  all  of  them  large,  one  weighing 
fifteen  pounds  (the  size  apparently  the  sole  cause  for  still  birth  and  frac- 
ture). All  the  cases  were  at  full  term,  twenty-three  in  multiparee,  in  whose 
children  fractures  of  extremities  seem  more  common  than  in  children  of 
primiparae,  perhaps  because  of  the  greater  liability  to  large  children.  Some 
operative  interference  was  required  in  all  cases  but  two. 


304  REPORT   OF   THE   SOCIETV    OF   THE    LYIXG-TN    HOSPITAL. 

CoMPLIOA'riONS. 

Deformity  is  usually  the  result  of  improper  treatment,  but  in  time  cor- 
rects itself.  Musoulo-spiral  })aralysis  has  been  noticetl,  but,  as  Erb  points 
out,  Russian  children,  with  the  arms  tightly  swathed  to  the  body  and 
allowed  to  lie  for  a  long  time  on  one  side,  often  suffer  from  musculo-spiral 
paralysis  without  fractures.  This  paralysis  may  also  take  place  from  too 
tight  bandaging  (Loviot),  and  has  been  due  to  the  inclusion  of  a  nerve  in 
callus. 

No  case  of  shortening  from  e]nphyseal  separation  or  chronic  osteitis 
has  apj)earetl  as  yet  in  this  series,  nor  have  any  cases  of  epiphysitis. 

Prognosis. 

Two  of  the  humeri  in  this  series  needed  refracture,  but  the  one  which 
refuseil  treatment  had  very  slight  deformity  two  years  later.  Six  cases 
were  still-born  or  died  within  forty-eight  hours.  Probably  the  deaths 
were  from  other  causes  than  the  fracture,  in  view  of  the  recovery  of  two 
chiUlren  with  fracture  of  the  skull  as  well  as  of  the  humerus.  Unfortu- 
nately no  autopsies  were  to  be  had  to  prove  this  assertion. 

AN'ithin  seventeen  days  these  fractures  usually  solidlv  unite,  although  at 
the  ninth  and  tenth  days  many  of  them  appear  perfectly  firm,  notably 
those  near  the  ends  of  the  shaft  and  those  in  good  position. 

Symptoms. 

A  snap  is  heard  at  the  moment  of  fracture ;  crepitus  is  often  faint,  and 
like  that  of  an  (jld  l)lood  clot  rather  than  that  of  adult  bone.  An  abnor- 
iiud  ])oint  of  motion  is  usually  easily  made  out.  This  may,  however,  be 
oltscure  if  the  fracture  be  under  the  deltoid  muscle,  or  if  the  periosteum  be 
iKtt  divided.  DeJ'ormity  is  not  often  marked,  as  the  muscles  are  too  weak 
to  hold  the  bone  in  an  abnormal  position.  The  writer  has  found  most  of 
these  fractures  com])lete  (not  "green  stick"),  the  line  of  fracture  nearly 
transverse,  with  little  or  no  splintering,  in  the  upper  one-third  of  the 
shaft,  about  the  insertion  of  the  deltoid  muscle.  If  fracture  be  un- 
lutticed  for  some  days,  the  large  callus  often  developed  may  call  atten- 
tion to  it.  The  children  arc  irrital)le  and  cry  out  at  night  in  the  same  Avay 
that  osteosco])ic  pains  cause  "night  cry"  in  older  children.  The  arm 
hangs  useless,  and  is  tender  on  manipulation. 

DiAfJNOSIS. 

The  physician  shoidd  distinguish  a  liiictiirc  from  Erb's  paralysis  with 
its  late  disl(x;ations  of  shoulder  j<»int;  fi-om  pseudo-])aralysis  of  syphilis 
(osseous  dystroj)jiy):  from  fa-tal  malformation  and  fi-om  dislocation.  Tiruiis 
has  report«'d  an  intrauterine  sarcoma  of  the  humerus,  which  would  be  iiai-d 
to  distingui-sl)  from  the  callus  of  an  intrauterine  fracture.  The  Rontgeii 
photography  will  i.pobably  iiclj)  greatly  in  dillVivntiations. 


FRACTL'KES   IN    THE    NEW    BORN.  305 


Treatment. 

The  writer  believes  that  a  gypsum  (plaster  of  paris)  case  around  the 
chest,  and  the  arm  bound  to  the  case  after  reduction  of  the  deformity, 
either  with  plaster,  starch,  or  ordinary  gauze  bandage,  meets  all  the  require- 
ments of  immobilization.  If  not  applied  with  care,  this  may  impede 
respiration.  A  towel  folded  over  the  chest  and  removed  after  the  plaster 
is  hard,  prevents  that  danger.  This  dressing  may  cause  erythema,  des- 
quamation, and  even  erysipelatous-looking  eruptions,  which  render  the 
patients  exceedingly  uncomfortable.  Drying  powder  and  white  flannel 
beneath  the  dressing  usually  eliminates  this  difficulty.  If  the  arm  be 
bandaged  to  a  well-padded  case  there  will  be  no  danger  of  gangrene  or  of 
musculo-spiral  paralysis  due  to  pressure.  It  is  well  to  caution  the  nurse 
against  permitting  a  child  to  lie  on  the  injured  side,  even  if  weU  protected 
by  a  solid  case.  Splints  are  exceedingly  unsatisfactory,  because  they  slip 
readily  and  cause  permanent  deformities,  which  may  require  refracture. 
Such  slipping  ma}^  delay  union,  as  in  three  cases  of  this  list.  If  gypsum, 
silicate,  or  starch  bandages  are  not  used,  it  is  better  to  bandage  the  arm  to 
the  side  of  the  chest  with  cardboard  at  the  inner  side  of  the  arm,  because 
then  there  is  less  liability  to  displacement  than  with  splints.  The  enforced 
absence  of  bathing  does  the  child  no  harm,  and  may  be  a  distinct  advan- 
tage. 

These  are  ideal  cases  for  the  treatment  by  massage  without  retentive 
apparatus,  on  account  of  the  weak  musculature,  small  liabiUty  to  spasms 
or  re]3roduction  of  reduced  deformity,  and  on  account  of  their  rapid  heal- 
ing even  without  treatment.  The  child  will  hold  a  fractured  arm  approxi- 
mately still,  and  displacement,  therefore,  can  only  take  place  by  nursing 
and  handling. 

BiBLIOGEAPHY    OF    FrACTURES    OF    HuMERUS. 

General  references  above. 

Hamilton:  Sth  ed.,  Philadelphia,  1891,  p.  227. 

Lowenhardt:  Am.  Jour.  Med.  Science,  Philadelphia,  Jan.,  1841,  p.  250. 
Western  Med.  and  Surg.  Kep.,  St.  Joseph,  Mo.,  Jan.,  1891. 

Gerber:  Der  Kinder  Arzt.,  Worms,  May,  1893. 

Loviot:  Ann.  de  gynecolog.  et  obstet.,  Paris,  June,  1895. 

Berry  (J.  J.):  Kew  England  Med.  Month.,  J^ewtown,  Conn.,  1892- 
93,  p.  257. 

Kleber  (J.  C):  Handel  v.  h.  Genersk.  Genootsch.,  Amsterdam,  1777, 
p.  251. 

Fractures  of  Forearm. 
ISTone  in  this  series. 

Fractures  of  Pelvis. 

There  are  none  in  this  series.      As  the  pelvis  in  the  foetus  is  relatively 
smaller  than  the  shoulder  or  cephalic  girdle,  and  well  covered,  there  is  very 
little  danger  of  its  breaking.     Euge,  however,  reports  three  cases  of  rup- 
ture at  the  sacroiliac  joint. 
20 


306  REPORT   OF   THE   SOCTETV    OF   THE    LYTXG-TX   HOSPITAL. 

nUiLIOGKAl'lIY. 

Ruge:  Ztschr.  f.  Geburts.  u.  Frauen  Kr.,  Stuttgart,  1875-7(i,  p.  OS-90. 

Fkactures  of  Femtij. 

Etiohxfy. — In  breech  presentation  or  in  jHxlalic  version,  if  the  child's 
leg  be  extended  behind  its  back,  the  leg  is  certain  to  be  fractured  or  dislo- 
catetl.  In  })(jdalic  version  or  breech  extraction,  the  leg  should  be  flexed  on 
the  tliijrh,  and  the  flexed  lind)  rotated  inward  and  extended  across  the  abdo- 
men.  The  second  leg  is  prol)al)ly  usually  the  one  fractured.  The  mechan- 
ism of  fracture  of  the  femur  by  uterine  force  alone  is  skilfully  depicted  by 
Key  nulds  (Practical  Midwifery,  X.  Y.,  1892,  p.  248)  as  follows:  "In  breech 
presentation  with  the  sacrum  posterior,  the  mid  point  of  the  flexed  femur 
(leg  extendetl)  is  pressed  against  the  symphysis  pul)is  of  mother  with  sufli- 
cient  force  to  break  the  infant  l)one.'''  ]\[ensinga  reports  a  case  fractured 
l)y  the  use  of  the  blunt  hook  as  tractor  in  gi-oin;  ]\ratthews  Duncan  one 
when  the  tractor  in  groin  was  a  flllet.  If,  as  in  the  case  in  this  series,  the 
))i-<)nu3ntory  jutted  forward,  traction  on  the  foot  would  bend  the  femur 
acr(jss  such  a  ])ro)nontory,  while  the  body  of  the  child  firmly  held  the 
u])per  part  of  the  infant  femur  well  behind  the  eminence,  and  a  fracture  was 
as  easil}'  accomplished  as  if  the  bone  ^vere  broken  across  the  knee. 

Prognosis. 

The  prognosis  is  as  regards  life  good,  but  not  as  regards  shortening. 
Shortening  particularly  a])pears  if,  as  is  usually  the  case,  the  fracture 
fx?curs  above  the  junction  of  the  upper  and  middle  third  of  the  bones. 
The  uncompensated  action  of  the  psoas  iliacus  muscle  tends  to  tilt  forward 
tlie  upper  fragment.  The  diagnosis  is  easy,  save  possibly  from  congenital 
dishx-ation,  later  from  shortening  due  to  epi})liyseal  separation,  from  bend- 
ing of  the  neck  of  the  femur  (Whitman),  or  from  the  sciatic  paralysis  men- 
tioned by  Erb  as  occurring  in  breech  deliveries  with  extended  thighs  or  by 
traction  u))on  tho  foot. 

Symptoms. 

The  symptoms  are  the  same  as  in  fractures  of  the  luunerus,  but  the 
anatomical  [Kjsition  modifies  their  relation,  and  the  deformity  is  more 
marked,  owing  to  the  stronger  muscles  in  this  part  of  the  body. 

Ti;i;A'r>rK\T. 

A  (loid)lo  Liston  s])lint  fi-om  Ijotli  axillie  to  the  hods,  with  a  cross-bar 
at  the  feet,  separating  the  thighs,  for  convenience  in  dressing  and  cleansing 
the  child,  or  a  Pradford  franie  arc  good  when  the  fracture  is  in  the  lower 
half  of  the  bone.  Immobilization  is  tlnis  more  conveniently  secui'cd  than 
by  a  single  splint,  plaster,  or  by  sus])ension  of  the  cliild  by  tlie  legs. 

In  fractures  in  the  upper  thii-d.  tlie  method  suggested  by  Di-.  AVyeth 
would  probably  give  tlie  best  results;  that  is,  the  leg  flexed  upon  the  thigh, 
and  the  thigh  upon  the  lK>dy,  until  the  fragnnMits  of  the  Ijroken  femur  are 
in  accurate  apfMjsition  and  so  fixed  by  a  gvpsiiin  easeleft(»n  b.i-  twow<!eks. 


FRACTURES    IX    THE    NEW    BORN.  307 

BlBLIOGRAPPIY    OF    FeMORAL    FkACTURE. 

Partridge:  quoted  above. 

Mensinga:  (|noted  in  Brit.  Med.  Jour.,  London,  March  14,  1891. 

AVyeth:  N.  Y.  Med.  Jour.,  July  4,  1891. 

Gravel! :  Med.  Xews,  Philadelphia,  May  13,  1893. 

Owings:  Med.  News,  Philadelphia,  Nov.  25,  1893. 

Erb:  Zierasen  C3"cloptedia,  1876,  xi.,  j).  567. 

Breisky:  Prag.  Med.  Wochenschrift,  1879,  ix.,  244. 

Morton:  Lancet,  London,  1878,  i.,  223. 

O'Farrell:  Phila.  M.  Times,  1876-77,  vii.,  125. 

Ten  Eyck  (A.  P.):  Med.  Ann.,  Albany,  1880,  i.,  9-11. 

Feactdees  of  the  Tibia  and  Fibula, 

There  were  no  fractures  of  this  character  in  the  series.  Such  a  case 
occurred  in  the  indoor  service  of  the  Hospital,  however,  and  will  be 
reported  in  detail  at  some  future  time.  See  history  e,  C.  N.  225  (indoor 
history). 

BiBLIOGEAPHT    ON    FeACTUEES    OF    THE    TiBIA    AND    FiBULA. 

Simpson:  Obs.  J.  W.  Brit.,  London,  1880,  viii.,  553. 

Multiple  fractures,  not  at  once  causing  fatal  issue,  seem  from  these  his- 
tories to  do  better  than  in  adults,  in  whom  shock  is  a  greater  factor.  Shock, 
if  occurring  at  all  in  infants,  would  probably  be  only  a  respiratory  stim- 
ulus. The  child  with  both  clavicles  fractured  and  the  one  with  skull  and 
humerus  both  did  very  well. 

Summary. 

Coston  says  the  dangers  of  breech  deliveries  to  a  child  are :  pressure  on 
the  cord,  asphyxia,  traumatisms  to  the  head,  intracranial  haemorrhages, 
slipping  of  an  arm  over  the  head,  fractures  of  the  humerus,  contraction 
of  an  incompletely  dilated  os  uteri  around  the  neck  of  the  child.  The 
writer  would  add:  fracture  of  the  clavicle,  Erb's  paralysis  from  the  Smellie- 
Yeit  method  of  delivery,  fractures  of  the  femur  from  extended  legs,  sciatic 
paralysis,  fractures  of  the  tibia  from  the  use  of  a  fillet. 

BiBLIOGEAPHT. 

Coston:  Therapeutic  Gazette,  Detroit,  1896,  xxxv.,  p.  604. 


PLACENTA  PREVIA. 

By  George  E.  White,  M.D. 


Amont,  the  first  10,000  cases  delivered  by  the  Hospital  were  31  cases 
of  })lacenta  pra?via,  which  are  ])resented  briefly  in  the  table  on  opposite 
page. 

Definition. 

This  term  was  first  used  to  designate  a  placenta  that  Avas  supposed  to 
have  become  detached  and  gotten  below  the  head  of  the  child.  At  present 
the  term  means  an  implantation  of  the  placenta  in  the  lower  part  of  the 
uterus  covering  more  or  less  of  the  zone  which  must  dilate  during  labor. 
Before  labor  begins,  this  zone  extends  between  2^  and  3  inches  above  the 
internal  os.  When  the  placenta  occupies  part  of  this  zone,  but  does  not 
extend  over  the  dilated  cervix,  the  condition  is  called  "placenta  pra?via 
marginalis; '"  wlien  the  dilated  cervix  is  covered  partly  with  placenta  and 
partly  with  membranes,  it  is  called  "placenta  pra?via  partialis,"  and  when 
the  dihited  cei-vix  is  covered  entirely  ])y  ])lacenta,  it  is  called  "placenta 
praevia  centralis."  The  latter  term  does  not  imply  tliat  the  placenta  is 
directly  central,  as  that  is  a  condition  rarel}^  met  with.  Many  writers, 
including  Parvin  and  MuUer,  make  but  two  subdivisions,  complete  and 
partial. 

Frequency. 

Tliis  condition  occurs  31  times  in  Jo.odo  cases,  or  1  to  322.  This 
number  is  somewhat  higher  than  the  normal  ratio,  since  some  of  the 
])atients  were  consultation  cases  referred  to  the  IIos])ital  by  outside  physi- 
cians an<l  midwives.  In  over  800, OOO  deliveries  tiibiilated  by  IMiillci-,  this 
condition  occurred  about  J  to  1, ()()(»;  and  in  (Kmijkh)  cases  tabulated  1)V 
Parvin,  it  was  present  about  1  tf)  l,2<-'0. 

The  distribution  of  our  cases  has  been  nov  uneven.  TJins  t  Iiei'o  were  (! 
among  tlie  first  500  cases,  wliile  at  anotliei-  lime  tlier<>  were  over  2,000 
delivj-ries  witli  but  a  single  case-  of  jdacenta,  ])i-a'via.  This  une(|u;il  distri- 
bution is  alsf>  noted  by  Sa.xtorj)!!  and  by  iS'iigle  (K.  Iligby,  jMidwifer^',  ]>. 
504),  who  states  that  in  some  years  ])lacental  presentation  is  so  frequent 
that  it  seems  as  if  it  were  almost  epidemic. 


PLACENTA   PREVIA. 


309 


OJ 

■S 

.  si 

a 
0 

'to 

1 

.D 

-3       .2  j- 
m         r^  CD 

athed  a  few  times. 

d  of  atelectasis,  6  hours 

irt  heard  in  first  stage. 

p 

K 

4. 

p 
S 

3 

o 

CD 
a 

5  p 
C.2 

Is 

-P  O 

'5?i 

-3 

3 

a 
si 

3 

art  not  heard. 

ervix     contracted    i 
neck;  decapitated. 

art  not  heard. 

art  heard ;  not  count 

pressed   fracture  pa 
one ;  fracture  of  hum 
art  heard  after  birth. 

CD 

a 

■2 

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1 

3111  REPORT   OF  THE   SOCIETY'    OF    THK    LVIXG-IX    HOSPITAL, 

Re^J-aiiliii"-  the  friHjUOiu'V  of  tho  ditVoi-ent  implaiUatioiis,  tliere  is  some 
(litticultv  in  getting  satisfactory  statistics,  as  different  metliods  of  classifi- 
cation are  adopteil.  ^fiiller  in  270  cases  found  20  per  cent,  central.  Town- 
send  (IJost.  Med.  and  Surg.  Jour.,  IS*.);},  p.  129)  in  his  28  cases  found  15 
nuirginal,  S  hiteral,  5  central,  or  IS  percent,  central.  Boss  (Med.  Kec, 
Feb.  1,  1S1>«'»)  in  13r>  casos  found  28  per  cent,  central,  01  per  cent,  partial, 
and  11  percent,  marginal.  TJiese -lo;^  cases  give  about  22  per  cent,  cen- 
tral. (  Uir  statistics  show  10  central  (;>2.2  per  cent.);  9  partial  (29.2  per 
cent.),  and  12  marginal  (88. 0  per  cent.). 

UCCIKKENCE. 

It  is  often  stated  tliat  j^lacenta  pra'via  occurs  most  frequently  in  old 
multipara^  with  relaxed  uterine  walls.  Thus  ]Muller  gives  the  ])roportion 
of  })rimi})ara^  as  1  to  0,  but  that  is  not  far  fi-oni  the  normal  ratio  of  first  to 
subsecjuent  ])regnancies,  and  it  seems  doubtful  if  uudtiple  pregnancies  have 
anything  to  do  with  the  occurrence  of  the  condition.  Townsend,  among 
28  cases  at  the  Boston  Lying-in  Hospital,  reports  11,  or  about  io  per  cent. 
of  the  ca.ses  in  ])rimi|)ara\ 

Our  cases  are  distributed  as  follows: 

Cases. 

The  1st  pregnancy 4 

''2d  "       ' 9 

"3d  "  1 

"4th  •'  6 

"    5th         "  2 


The    6th 

"      Sth 

pregnancy  .... 

Cases. 

2 

2 

"      9th 

u 

1 

"    10th 

u 

3 

"    13th 

u 

1 

The  second  pregnancy  furnishes  29  per  cent,  of  our  cases. 
This  distribution  seems  to  be  purely  accidental. 

ETior,()(;v. 

The  cause  of  the  trouble  is  still  unknown.  Parvin  attributes  placenta 
pra'via  to  a  diseased  endometrium,  which  is  apt  to  cause  frecpient  al)ortions, 
but  anuing  our  cases  only  foui-  had  liad  ])rcvious  abortions.  Man}'  writei's 
are  of  the  o))iiiioii  that  it  is  simply  due  to  a  ]o\\'  attachment  of  the  pla- 
centa. Ilofmein- (/iir  Anatomic  line  .Ktiologic  dcr  i'lacenta  l*ra>via,  1890) 
and  more  rj'ccntly  JvaltcMbach  liave  advanced  iIk;  theory  that  the  choi'ionic 
villi  develop  in  ihc  dccidiia  icllexa  as  well  as  in  the  serotiiia,  and  the 
refle.xa  subsecjueiitly  beconuis  attached  to  th(^  vera,  forming  a  ])art  of  the 
placenta.  If  this  process  takes  ))lace  in  the  lower  pole  of  the  ovum, 
the  cervix  is  liable  to  be  more  or  less  covered. 

Pljicentii  succentnriata  and  the  f)ther  mallV)rmations  are  sup])Osed  to  be 
formed  by  a  similar  pn^cess.  Anu)ng  our  cases  theiM?  was  one  velamentous 
insertion  of  the  cord  and  one  markedly  lolnd  placenta.  No  case  of  pla- 
centa succenturiata  was  f(Mind.  althou^-h  it  is  not  an  nnc-ommon  (-oniplica- 


PLACENTA   PRiEVIA. 


311 


tion.  In  one  case  (729)  the  placenta  covering  the  cervix  was  so  very  thin 
and  non-vascular  that  labor  was  terminated  without  any  interference. 
According  to  this  theory,  the  condition  is  due  to  an  anomaly  of  develop- 
ment of  the  ovum,  and  the  cause  is  foetal  rather  than  maternal.  Barnes, 
Hart  (Brussels  Congress,  1892),  Ahlfeld,  and  others  oppose  Hofmeier's 
views  and  adhere  to  the  theory  of  the  low  implantation  of  the  ovum. 
Hart  asserts  that  it  is  no  uncommon  thing  for  the  chorionic  villi  to  grow 
into  tlie  decidua  retlexa,  but  they  subsequently  atrophy  and  do  not  form 
part  of  the  placenta. 

Complications. 

Faulty  presentations  of  the  child  are  of  common  occurrence,  owing 
undoubtedly  to  the  placenta  occupying  the  space  usuall}^  filled  by  the  pre- 
senting part. 

Shoulder  presentations  were  seen  in  9  of  our  cases,  or  in  29  per  cent. 
If  these  9  are  excluded,  this  presentation  forms  less  than  0.8  per  cent,  of 
the  10,000  cases. 

The  breech  presented  but  once,  and  in  that  case  the  child  was  prema- 
ture. It  would  seem  that  placenta  preevia  does  not  predispose  to  breech 
presentation. 

Twins  occurred  twice. 

Symptoms. 

The  chief  symptom  of  placenta  prtevia  is  haemorrhage.  This  may  come 
on  at  any  time  after  the  placenta  is  formed,  but  rarely  before  the  sixth 
month. 

Those  who  believe  in  the  theory  of  the  low  implantation  of  the  ovum 
claim  that  it  is  a  frequent  cause  of  abortion. 

Among  our  31  cases  the  first  hsemorrhage  occurred  as  follows: 


Cases. 

In  the  5th  month 1 

"       6th      "      5 

"      7th      "      5 


Cases. 

In  the  8th  month 8 

At  or  near  term 12 


Dilatation  of  the  lower  segment  of  the  uterus  during  labor  is  one  of 
the  causes  of  hasmorrhage,  but  not  the  only  one,  as  hgemorrhage  sometimes 
takes  place  without  any  sign  of  labor,  beginning  perhaps  while  the  woman 
is  asleep.  This  is  probably  caused  by  want  of  uniformity  in  growth  of 
the  placenta  and  lower  uterine  zone.  The  placental  site  is  supposed  to  grow 
more  rapidly  than  the  placenta  and  tear  open  the  uterine  sinuses. 

Haemorrhage  occurring  before  labor  usually  comes  on  without  any  warn- 
ing. The  first  attack,  as  a  rule,  is  not  severe,  but  is  almost  certain  to  be 
followed  by  others,  increasing  in  severity  as  pregnancy  advances.  Excep- 
tionally, the  first  attack  may  be  fatal.  In  other  cases  there  is  a  constant 
oozing  of  blood,  which  keeps  on  until  the  patient  is  exsanguinated. 


ol'.i  REPORT   OF  THE   SOCIETY   OF   THE   LYING-IN   HOSPITAL. 


Diagnosis. 

The  (.liairnosis  is  made  bv  feelino-  tlie  placenta.  This  may  sometimes 
be  done  bv  abdominal  i)al[)ation  or  vaginal  examination  before  labor 
begins. 

AVhen  the  cervix  is  dilated,  the  diagnosis  presents  no  dirticulty,  except 
in  some  cases  of  marginal  implantation,  in  Avhich  the  edge  of  the  placenta 
becomes  detached  from  the  lower  zone  and  remains  suspended  in  the  cervix, 
surrounded  by  blood  clots.  The  examining  linger  may  then  be  passed 
around  the  entire  lower  zone  of  the  uterus  without  feeling  the  placenta,  and 
one  is  a])t  to  make  an  error  unless  the  entire  surface  of  the  presenting* 
membranes  be  examined. 

The  diagnosis  was  not  made  in  any  of  our  cases  before  haemorrhage 
began. 

Prognosis. 

The  prognosis  depends  largely  upon  tlio  time  the  patient  is  seen,  the 
method  of  treatment,  and  skill  of  the  operator. 

Miiller,  in  an  analysis  of  1,574  cases,  puts  the  maternal  mortality  as  not 
less  than  3<'>  to  4(>  ])er  cent.,  and  the  fa^tal  mortality  as  (U)  per  cent. 
Ahlfeld  ]nits  the  maternal  morttdity  at  2.")  ])er  cent.  Winckel  claims  it 
ought  not  to  be  over  5  to  1(»  per  cent.,  while  the  foetal  mortality  is  seldom 
less  than  50  per  cent.,  and  often  75  per  cent,  or  more. 

Tkeatment. 

No  single  operation  will  suffice  for  all  cases,  but  treatment  depends 
u]ton  the  condition  of  mother  and  child  and  the  location  of  the  ])lacenta. 
While  stnne  cases  do  well  with  a  purely  exjiectant  plan  of  treatment  or 
early  rupture  of  the  membranes,  others  can  barely  be  saved  by  most 
prom])t  an<l  skilful  opei-ative  i)rocedure. 

IVrliaps  the  oldest  method  of  treating  this  condition  is  tliat  known  as 
accouchement  force.  A  satisfactory  definition  of  this  term  is  not  easy  to 
find ;  the  dictionaries  ])ara])hrase  it  in  several  languages,  but  do  not  define 
it.  Foster  states  that  it  is  a  forcible  termination  of  labor  by  version  or 
force])s;  l)ut  this  is  a  sense  in  which  it  is  never  used.  Parvin  (Am.  Text- 
I'o<;k  of  Obstet.,  ]).  5!m;)  asserts  that  the  term  has  undergone  a  change  of 
jueaning,  whicli  is  undoubtedly  the  case.  As  used  by  the  older  writers, 
it  meant  (h-igging  a  child  through  an  undilated  cervix.  As  used  at  the 
Lying-in  Hospital,  the  term  means  artificial  termination  of  labor  tlirougli 
the  natural  passages,  and  includes  manual  dilatation  of  the  cervix,  rupture 
of  tlie  membranes,  and  ra]>i(l  extraction  of  the  child  by  force])S  or  version, 
or  other  operations.     No  force  need  be  used. 

Altliough  this  method  is  condemned  by  AVinckel,  husk,  i'arvin,  and 
most  obstetrical  writers,  it  is  the  irent  nieiiL  most  in  use  at  the  Lying-in 
Hospital,  and  at  present  is  used  almost  e.xeiusively  in  IIh;  severer  cases  in 


PLACENTA    PR /R VI A.  313 

wliicli  the  cliild  is  living-.     The  details  of  the  o])eration  are  given  in  a  sub- 
sequent paragraph. 

In  the  latter  part  of  the  last  century  the  vaginal  tampon  was  intro- 
duced by  Wigand  and  Leroux.  The  vagina  was  packed  as  soon  as  the 
diagnosis  was  made,  and  the  tampon  left  in  place  until  it  was  expelled  by 
the  advancing  child.  Wigand  states  that  in  a  large  obstetrical  practice  he 
lost  neither  mother  nor  child;  but  other  obstetricians  have  been  less  success- 
ful, and  the  procedure  is  not  in  general  use,  except  as  a  preliminarv  to 
other  measures.  Haemorrhage  can  be  stopped  at  once  by  a  well-applied 
tampon,  which  may  be  left  in  place  until  ready  to  operate.  There  is  but 
little  danger  of  severe  hcemorrhage  taking  place  above  the  tampon.  Parvin 
(Text-Book,  p.  388)  states  that  no  case  of  the  kind  has  ever  been  recorded. 
Eecently  Diihrssen  (Deu.  Med.  Wochenschrift,  1894,  p.  422)  has  reported 
a  fatal  case  of  haemorrhage  into  the  uterus  after  the  vagina  had  been  tam- 
poned b}''  a  midwife. 

The  tam])on  is  still  a  favorite  method  of  treatment  by  Tarnier.  As 
low  a  maternal  mortality  as  1.7  per  cent,  is  claimed  by  its  use  (Labus- 
quiere:  Ann.  de  gyn.,  Jan.,  1896,  p.  60).  Three  cases  of  placenta  pr^evia 
marginalis  were  treated  by  this  method  at  tlie  Lying-in  Hospital,  with 
favorable  results  to  all  the  mothers  and  two  children ;  the  other  child  was 
not  viable.  These  were  probably  cases  which  would  have  done  well  with- 
out any  treatment. 

Cohen's  method  consists  in  detaching  the  placenta  from  the  lower  zone 
of  the  uterus  and  leaving  the  deliver}^  to  nature.  Haemorrhage  often  ceases 
when  the  placenta  is  partially  detached  in  this  manner.  This  procedure 
has  been  used  in  several  of  our  cases,  in  addition  to  other  means  of  treat- 
ment, but  never  alone. 

Braxton  Hicks,  in  his  work  on  combined  external  and  internal  version, 
in  1864,  made  a  great  advance  in  the  treatment  of  placenta  pra?via.  His 
treatment  consists  in  version  by  the  method  which  bears  his  name,  plug- 
ging the  cervix  with  the  breech  to  prevent  haemorrhage,  and  leaving  the 
child  to  be  delivered  by  the  natural  forces.  This  method  is  in  very  exten- 
sive use  at  the  present  day,  and  some  obstetricians  report  excellent  results 
as  far  as  the  mother  is  concerned.  Thus  Duhrssen  saved  all  but  one 
of  twenty-two  mothers,  but  onl}^  three  children  survived.  The  same  author 
states  that  the  best  statistics  show  a  foetal  mortality  of  at  least  60  per  cent. 
Lusk's  statistics  show  178  cases  treated  by  eleven  operators,  with  only 
eight  deaths.  Other  obstetricians  are  not  so  successful  with  this  method. 
The  hemorrhage  does  not  always  stop  when  the  breech  is  brought  down. 
Speigelberg  has  pointed  out  that  this  is  because  the  haemorrhage  does  not 
come  from  the  cervix,  the  part  plugged  by  the  child,  but  from  a  point 
higher. 

One  case  (398)  of  breech  presentation  was  delivered  bv  this  method  at 
the  Lying-in  Hospital,  with  favorable  result  to  the  mother;  the  child  was 
dead  when  the  patient  was  first  seen,  and  this  operation  was  chosen,  as 
only  the  interests  of  the  mother  were  considered. 

The  method  most  in  use  at  present  is  often  attributed  to  Barnes.     It 


314  REPORT    OF    THE    SOCIETY    OF   THE    LVIXG-IX    HOSPITAL. 

consists  in  fully  dilating  tlie  cervix  Avitli  Ihirnes's  bays  and  delivering  the 
ihild  by  vei*sion  or  forcej)s.  The  results  vary  with  the  different  ojierators. 
Anionsr  the  best  stiitistics  arc  those  of  Thomas  (Trans.  N.  Y.  Obst.  Soc, 
vol.  i.,  j>.  2i'>2),  18  cases,  Avith  two  deaths;  one  from  sepsis  and  one  from 
]»osti)ai-tum  hannorrhagc.  Murphy  (Brit.  Mvd.  Jour.,  1893)  reports  only 
two  deaths  in  (>2  cases.  One  of  these  was  from  se])sis,  and  one  from 
h;emorrhagc  before  assistance  arrived.  The  children  did  not  fare  so  Avell. 
Onlv  three  lived  out  of  a  ])ossible  nine.  In  his  later  re])ort  the  children 
are  not  mentioned.  DUhrssen,  by  using  the  Champetier  de  Ribes  balloons, 
lost  but  one  mother  in  '2Ct  cases.  These  statistics  give  but  little  idea  of  the 
morlalitv  by  less  skilful  o})erators  working  under  less  favorable  conditions. 

At  the  Lying-in  llos])ital  the  Barnes  bags  have  been  used  live  times 
(Xos.  2<»2.  4.").'),  1.198,  8,4<)r),  0.231) — three  times  as  a  preliminary  measure 
for  manual  dilatation;  once  the  ])atient  refused  treatment,  and  was  dis- 
charged undelivered;  and  in  the  fifth  case  the  uterus  was  ruptured.  The 
case  is  given  lu'ieflv  as  follows: 

Xo.  1,198. — liussian  ;  \1.  para  ;  36  years  ;  six  months  pregnant. 
AVhen  lii-st  seen  the  patient  had  been  bleeding  alwut  twelve  hours;  the  cer- 
vix was  <lilated  a])()Ut  the  size  of  a  silver  quarter,  and  tlie  ])lacenta  was  felt 
attached  low  down  upon  the  left  side.  A  Barnes  bag  was  inserted  to  dilate 
the  cervix;  after  it  had  been  in  place  about  ten  uiinutes,  it  suddenly  ru])- 
tured.  The  cervix  was  dilated  enough  to  admit  the  hand,  and  the  child 
was  extracted  by  version.  Upon  introducing  the  hand  again,  a  coil  of 
intestines  was  drawn  out  and  the  uterus  found  to  be  ruj^tured  in  the  poste- 
rior }>art.  The  placenta  was  extracted  manually,  and  the  wound  in  the 
uterus  packed  with  gauze.  Tlie  child  was  still-born,  and  the  mother  died 
thirty-six  hours  after  delivery. 

Barnes's  bags  have  not  been  much  used  at  the  Lying-in  Hospital  for 
placenta  pncvia.  They  are  liable  to  ru])ture  at  a  critical  ])eriod  and  arc 
<litlicult  to  make  aseptic,  unless  they  are  put  in  the  steam  sterilizer,  which 
soon  spoils  them.  Moreover,  they  are  entirely  unnecessary,  as  the  iodo- 
ff»i-m  gauze  tam])on  and  nuinual  dilatation  are  much  more  satisfactory  means 
of  dilating  the  cervix. 

The  balloons  of  Cham])etier  de  Ililjcs,  wliicli  are  ])()))ular  in  many  of  the 
continental  clinics,  have  not  been  used  for  tliis  condition. 

None  of  the  otlier  methods  of  ti'catment  described  in  the  text-books  or 
recent  literature  has  been  tried. 

ClIOICK. 

The  choice  of  Ihf;  operations  depends  ciitii'dy  npon  ihv.  conditions  found. 
The  vaginal  tampon  suffices  in  many  cas<!S,  with  marginal  Implantation  of 
the  ]»lacenta.  Braxton  llicks's  method  is  useful  if  the  child  ])e  dead  or 
nonviable.  J'arnes's  bags  arc  now  rarely  or  never  used.  Accouchement 
fonx-  is  employed  in  nearly  all  the  severer  cases,  if  the  child  is  living 
and  viable. 

Jewett  states  that  patients  wlio  have  lost  nnich  Mood  stand  operation 
badly,  and  ad vi.ses  an  expectant  plan  of  treatment,  as  follows:  the  life  of 


PLACENTA   PREVIA.  315 

the  child  may  be  disregarded ;  hiemorrhage  checked  hy  a  vaginal  tampon ; 
stimulants  and  a  small  quantity  of  ergot  given;  and  delivery  left  to  nature, 
or  done  after  the  patient  rallies. 

Among  our  31  cases,  one  (729)  received  no  treatment;  three  were  treated 
by  vaginal  tampon  only;  one  was  delivered  by  pulling  down  a  foot  and 
leaving  the  delivery  to  nature;  in  one  case  Barnes's  bags  were  used  and  the 
case  left  undelivered,  and  25  were  delivered  by  accouchement  force. 

The  treatment  as  carried  out  at  the  Hospital  depends  upon  the  conditions 
found.  Cases  of  high  marginal  attachment  of  the  placenta,  in  which  the 
lower  edge  becomes  detached  and  causes  hgemorrhage  during  the  first  stage 
of  labor,  usually  require  no  special  treatment,  as  the  haemorrhage  is  not 
sufficient  to  cause  alarm,  and  the  descending  head  rarely  fails  to  check  it. 
If,  however,  anj^  treatment  be  necessary,  early  rupture  of  the  membranes 
or  a  vaginal  tampon  is  all  that  is  required.  If  the  patient  is  bleeding 
from  a  placenta  preevia,  a  vaginal  tampon  of  iodoform  gauze  is  inserted, 
and  kept  in  place  until  all  preparations  for  the  operation  are  made.  In 
cases  in  which  the  cervix  has  not  begun  to  dilate,  or  is  not  readily  dilat- 
able, the  cervix  and  vagina  are  packed  with  iodoform  gauze,  which  is  left 
in  place  four  hours  or  longer,  and  reinserted  if  the  first  tampon  has  not 
dilated  the  cervix  or  softened  it  sufficiently  to  admit  of  read}^  dilatation. 
The  operation  is  carried  out  under  the  usual  antiseptic  precautions,  the 
details  of  which  need  not  be  mentioned  here. 

After  giving  an  aneesthetic,  the  patient  is  placed  in  the  lithotomy  posi- 
tion. A  hand  is  passed  into  the  vagina,  and  dilatation  accomplished  by 
gradually  working  one  finger  through  the  cervix,  then  two  fingers,  and 
so  on,  until  the  whole  hand  is  admitted.  Dilatation  is  then  done  rapidly 
by  doubling  the  hand  into  a  fist  while  in  the  uterus  and  withdrawing  it. 
The  operation  is  often  very  tiresome.  In  some  cases,  as  soon  as  the  cervix 
will  admit  two  fingers,  both  index  fingers  are  inserted,  and  traction  made 
laterally  in  opposite  directions. 

When  possible,  the  cervix  is  dilated  thoroughly,  as  it  offers  considera- 
ble resistance  to  the  passage  of  a  head  after  it  will  admit  a  fist.  Hemor- 
rhage is  not  profuse  in  the  majority  of  cases,  probably  owing  to  the  fact 
that  the  lower  uterine  segment  is  but  little  disturbed  until  the  cervix  is 
quite  wide  open.  In  some  cases,  however,  profuse  haemorrhage  does  occur, 
and  requires  the  dilatation  and  version  to  be  done  very  rapidly. 

In  the  writer's  opinion,  Diihrssen's  incision  would  be  indicated  in  cases 
of  rigid  cervix  in  which  the  supravaginal  portion  is  obliterated,  and  the 
resistance  is  at  the  external  os;  but  no  case  in  our  records  has  required  that 
operation. 

After  the  cer\dx  is  dilated,  the  membranes  are  ruptured  or  the  placenta 
is  perforated,  if  necessary,  and  a  foot  brought  doAvn.  Delivery  is  effected 
as  soon  as  possible,  following  the  usual  methods,  being  careful  to  prevent 
the  arms  from  becoming  extended,  as  dela}^  from  the  after-coming  head  is 
liable  to  be  fatal  to  the  child. 

The  placenta  is  extracted  manually  soon  after  delivery,  as  hgemorrhage 
is  apt  to  persist  until  it  is  removed. 


310  REPORT   OF   THE   SOCIETY   OF   THE    LYIXG-IX    HOSPITAL. 

The  time  of  the  o]>eratii>u  varies  greatly,  owing  to  the  condition  of 
the  cervix.     It  was: 


Cases. 

55  minutes 1 

30       ••        2 

25       ••        2 

15       ••        1 


Cases. 

10  minutes 2 

5       '•        2 

8       "        ?> 


The  exact  time  was  not  recorded  in  tlie  other  cases. 

The  chiUlren  ai-e  fre(|uently  ])rematnre,  and  if  aspliyxiated  are  resnsci- 
tateil  l»y  the  most  gentle  measui-es.  Continuous  swinging  and  vigorous 
treatment  of  any  kind  is  a[)t  to  l)e  fatal  to  these  premature  babies. 

Results. 

In  considering  tlie  results,  allowance  must  be  made  for  the  conditions 
umler  which  the  operations  were  performed.  They  were  all  done  in  tene- 
ment houses,  with  most  unsanitary  surroundings,  and  often  not  seen  for 
several  hours  after  ha^morrhao-e  had  beo-un. 

There  were  four  maternal  deaths  among  our  3i>  cases,  or  13.3  per  cent. 
The  causes  of  death  were:  Sepsis,  ])ulmonarv  oedema  on  the  third  day  after 
lalxjr,  hiemorrhage  before  assistance  arrived,  and  rupture  of  the  uterus. 

Of  the  32  children,  including  two  cases  of  twins,  six  had  not  reached 
the  age  of  viability,  four  were  dead  when  first  seen,  four  died  during 
labor,  and  three  died  soon  after  delivery.  This  gives  a  total  mortality  of 
17,  or  53.1  per  cent.  Excluding  the  nonviable  and  dead  children,  15  were 
siived  out  of  a  possible  22,  or  a  mortality  of  31.8  per  cent.  Of  those 
which  dird  during  lal)Oi'.  tlie  death  in  most  cases  could  be  attributed  to 
delay  bcl'oi-e  opci-ating.  Of  those  whicli  died  soon  after  delivery,  one  was 
])remature  and  died  of  atelectasis  six  hours  after  birth,  and  its  death  was 
not  due  in  any  way  to  the  method  of  operation. 

AViiile  tiiese  results  are  not  entirely  satisfactory,  they  refute  tlie  state- 
ment of  Pacjuy  (Gaz.  med.  de  Paris,  03,  Xo.  4!>)  and  others,  that  the  fa'tal 
mortality  is  so  high  that  the  life  of  the  child  should  be  disregarded. 

In  a  w«'ll-e(juipjM'd  hos])ital,  where  the  cases  can  be  seen  early,  the  mater- 
nal mortality  <night  to  l;e  mucii  smaller  than  these  statistics  show%  and  our 
mortiility  of  31.8  i)er  cent,  of  viable  children  reduced  at  least  a  half. 


REPORT   OF   THE   CURATOR. 

By  Jabies  W.  Markoe,  M.D..  and  Martha  Wollstein,  M.D. 


This  report  is  intended  to  cover  a  period  of  nearly  six  years,  but  owing 
to  the  impossibility  of  preparing  and  storing  specimens  during  the  first 
years,  when  the  work  was  performed  in  part  at  the  Dispensary  in  Broome 
Street  and  in  part  at  the  laboratory  of  the  Embryologist,  it  was  necessarily 
incomplete.  Thus  many  of  the  early  specimens  were  lost,  and  it  is  only 
within  the  past  two  years  that  they  have  been  systematically  prepared. 
Even  at  the  present  time,  the  only  place  provided  for  the  purpose  is  entirely 
inadequate. 

It  can,  therefore,  be  but  an  outline  of  the  preparations  at  present 
mounted  upon  the  shelves  of  the  Museum,  together  with  the  various 
models. 

The  wet  specimens  are  prepared  either  in  alcohol  or  formaline,  and 
are  arranged  in  such  an  order  that  they  may  be  referred  to  during  the 
course  of  any  lecture. 

In  addition  to  the  wet  specimens,  wax  models  and  similar  preparations 
have  been  purchased  abroad,  and  have  also  been  prepared  by  members  of 
the  Medical  Board.  These  form  a  very  valuable  addition  to  the  depart- 
ment. 

Collection, 

22  models  of  normal  pelves,  male  and  female. 

22  models  of  deformed  pelves. 

2  rubber  pelves.     Tramond,  Paris. 

1  wax  model  of  the  female  pelvis  (median  section),  with  a  portion  of 
the  vertebral  column,  showing  the  relations  of  bladder,  uterus,  and  rec- 
tum; also  the  external  genitalia.     Tramond,  Paris. 

1  ovology  set,  showing  the  formation  of  the  ovule  in  the  ovary,  its 
course  in  the  tube,  and  its  fecundation,  allowing  all  the  modifications  that 
the  germ  and  its  envelopes  undergo  to  be  followed  from  the  first  to  the 
thirtieth  day ;  that  is,  from  the  appearance  of  the  oyuIq  in  the  ovary  to  the 
formation  of  the  embryo.     Auzoux.,  Paris. 

1  wax  model  human  uterus,  pregnant.  Three  months'  foetus  in  mem- 
branes.     Tramojul,  Paris. 

1  series  of  His  models  of  human  embrvos,  comprising  8  models  in  the 
first  month  of  development.     Ziegler,  Freiburg. 


318  REPORT   OF  THE   SOCIETY   OF   THE   LYIXG-IX   HOSPITAL. 

1  series  of  His  models  of  liunuin  einbryus,  foiiiprising  S  models  in  the 
second  month  of  development.     Ziegler,  Freiburg. 

2  mo<.lels  of  the  development  of  the  human  embryo  (wax).  Ziegler, 
Freihury. 

1  series  of  His  models  of  chick  embrvos,  comprising  23  models,  enlarged 
fortv  times  the  real  size.  The  first  9  models  show  the  development  of  the 
fii*st  and  second  days  of  ineubation;  tlie  next  4  models  show  tlie  third  and 
fourth  days;  numbers  14  to  17  are  bj-ain  models;  IS  to  21,  hearts;  and  22 
to  23  intestine.     Z'n</h>i\  FreiJud'tj. 

1  series  of  His  models  of  the  develo])ment  of  tlie  human  brain  (wax), 
com})rising  S  models  from  embryos  of  4  weeks  to  3  months.  Zieyler, 
Freihury. 

1  series  of  Ecker  models  of  the  development  of  the  convolutions  of  the 
cei-ebral  liemis])lieres  in  the  human  foetus,  comprising  14  models  which 
show  7  stages  of  development  in  embryos  from  12  to  36  weeks  old.  Ziey- 
ler, Freihury. 

1  series  of  ]^Ian/.  models  of  the  development  of  the  e3^e  in  vertebrates, 
comprising  0  models.     Ziegler^  Freihurg. 

1  series  of  His  models  of  the  development  of  the  internal  ear  (human), 
P'our  models  in  embryos  4  weeks  to  2  months  old.     Z'teyler,  Freihury. 

1  series  of  Rose  models  of  the  development  of  human  teeth.  Six 
models  from  embryos  2  to  30  centimetres  in  length;  finally,  the  second 
temporary  and  the  first  permanent  molar,  just  prior  to  birth.  Ziegler, 
Freihury. 

1  series  of  His  models  of  tlie  development  of  the  human  heart.  Twelve 
models  from  embr3'os  2  millimetres  in  length,  to  the  fifth  week.  Ziegler, 
Freihury. 

1  scries  of  Born  models  of  the  development  of  the  mammalian  heart, 
comprising  11  models,  magnified  sixty  times  the  real  size,  showing  7 
stages  of  development,  including  the  aortic  arches  in  3.     Zieyler,  Freilmry. 

1  series  of  Born  models  of  the  development  of  the  human  heart,  com- 
prising 3  models  which  show  2  stages  (lieginning  of  the  third  and  middle 
of  the  sixth  month)  in  the  formation  of  the  auricular  septa  anil  valves. 
Ziegler,  Freihury. 

2  models  in  clay  of  vagina.      I)r.  Luiuhert. 

3  models  of  uterus:  (1)  unimpregnated;  (2)  first  month  of  pregnancy; 
(3)  second  month  of  pregnancy;  natural  size.      />/•.  Kdyar. 

7  corrosive  ])re])arations  of  placenta'.     Dr.  JJuiiiinyfon. 

1  models,  clccti-otypc,  laceration  of  ])erineum  with  sutures  in  place. 
Pla.ster  covered  willi  thin  layer  of  cojjpei-.      />/■.   F/yar. 

2  normal  skulls  of  fcetiis  at  birth.      Truinond,  Pai'is. 

1  skull  showing  result  of  o('ripitf)-])ostei'ioi'  ])osition.      Trnmond,  Paris. 

2  normal  skulls  of  younger  einbiyos.      I^uhiioik}.  Paris. 

1  skull  of  fd'tus  at  birth,  showing  (lee])  depression  of  left  ])arietal  Ixme, 
made  by  forcops. 

1  skull  of  ffX'tus  at  term,  sliowiiiH^  li-ietin'e  :iii(l  over-i'idiiig  of  both 
parietiil  bones,  tlie  result  of  eniiiiotoinv. 


REPORT  OF  THE  CURATOR.  319 


Wet  Specimens. 

In  addition  to  loO  specimens  mentioned  in  the  previous  Keports  of  the 
Hospital,  32  in  the  first  and  68  in  the  second,  tliere  are  T-t  which  have 
been  prepared  and  classitied  as  follows: 

Placenta  and  nnil)ilical  cord,  showino-  calcareous  deepen- 

eration,  twin,  and  other  abnormalities 5 

Umbilical  cord,  volvulus 1 

''  "      double  knot 1 

Monsters  5 

H3^drocephalic 1 

Anencephalic 2 

Cretin 1 

Diaphragmatic  hernia 1 

Twins 4 

Embryos 30 

Longitudinal  median  section,  showing  relations  of  all  the 

viscera  1 

Longitudinal    median   section,    showing   all   the    serous 

cavities 1 

Foetus  at  term  3 

Foetal  organs 14 

Heart,  lungs,  and  thymus  gland 4 

Kidneys,  ureters,  and  bladder 4 

Brains  (2  hydrocephalic) 5 

Intestinal  stenosis 1 

Longitudinal  section  through  thigh,  leg,  and  foot,  show- 
ing diaphysis  and  epiphysis  of  femur  and  tibia,  also 

patella  and  bones  of  foot 1 

Uterus  of  mother  from  cases  of  rupture,  Cgesarean  sec- 
tion, etc 8 

Total  number 74 

Some  of  the  specimens  are  mounted,  others  are  still  in  various  stages 
preparatory  to  a  permanent  mount  in  alcohol  or  formaline. 

For  several  months  past  the  method  of  Jores,*  which  aims  to  preserve 
the  natural  color  of  the  organs  and  tissues,  has  been  used  both  for  embryos 
and  viscera.  The  results  thus  far  obtained  have  been  eminently  satisfac- 
tory. 

*  Centralblatt  fiir  AUgemeine  Patliologie  unci  Pathologische  Anatomie,  bd.  vii., 
No.  4. 


REPORT  OF  ORTHOPEDIC  SURGEON. 

Fro.ai  April  1,  1893,  to  April  1,  189G. 

By  T.  Halsted  Myers,  M.D. 


Six    thousand   seven    hundred   and    sixty   cases   of   confinement   were 
attendeil  Ijv  the  physicians  of  this  Society  during  this  j^eriod. 

Sixtv  cases  of    deformity   were   noted,    wliich    may    be   tabulated   as 

follows! 

Cases.  Cases. 

AiK'ncepliahis 9 

Absence  of  lingers  and  toes 1 

right  Jiand 1 

Cleft  palate 8 

Deformity  of  hands  and  feet. ...  1 

E])iithyseal  se|)aration 1 


Ilydrijcephalus 4 

and  ta]i])es  varus.  1 

Hare  li). 8 

I leforinity  of  genitals,  su- 

])('i-nuinorary  fingers  and  toes .  1 

Imi»crf(»rate  anus 3 

Monster 2 

Phimosis 2 


Rudimentary  tail 

Spina  bifida 

Su])ernumerary  fi n gers 

"  toes  .  . 


fingers  and  toes . 
auricle 


Talipes    varus    and    im])erfo]-ate 

anus 1 

Talipes  varus 11 

Teeth  atbirtli 1 

Weljbed  toes 1 


fint'-ers 1 


.tal 


r.o 


Poh/thirti/IiKm. — The  cases  of  siipciiniinciary  lingers  and  toes  presented 
nearly  all  the  varieties  known,  and  the  following  are  detailed  as  examjOes: 

It  was  im))ossiblo  in  the  first  case  to  secure  ])]iotogi'a])lis  of  the  hands 
an<l  feet,  therefore  rough  sketclu'S  are  given. 

The  riglit  hand  was  norniiij.  except  that  a  I'udiinentaT-y  tei-niinal  ])lia- 
lanx.  with  nail,  was  attached  by  a  very  thin  pedicle  of  skin,  one-eight li  of 
an  inch  long,  t(^  the  fifth  finger,  op])osite  Hh'  joint  between  the  second  and 
third  phalanges  (Fig.  I). 

The  left  liand  was  normal,  exce])t  that  a  similar,  but  somewhat  better 
developed,  terminal  ]>halanx,  with  nail  and  cartilage,  was  attached  b}' a 
fleshy  ])edicle  to  the  fifth  finger,  opposite  the  middle  of  the  thiid  piialanx 
0:\'  2). 


REPORT   OF   ORTHOPEDIC   SURGEON.  321 

The  great  toe  of  the  right  foot  has  t\vo  terminal  pliahmges,  Avith  sepa- 
rate bones  and  partly  divided  nail,  articulating  with  a  single  broader  prox- 
imal ])halanx.  The  second  and  third  toes  are  Avebbed  up  to  the  terminal 
phalanx ;  the  fifth  has  a  double  terminal  plialanx,  each  with  its  nail,  but 
both  articulate  Avith  the  same  proximal  phalanx  (Fig.  4). 

The  left  foot  presents  a  A^ery  similar  deformity,  but  in  this  case  the 
great  and  fifth  toes  have  all  their  phalanges  double.  The  sketches  shoAV 
the  extent  of  the  Avebbing  in  each  case  (Fig.  5). 

The  family  history  in  this  case  is  remarkable.  This  boy's  grandfather 
had  six  fingers  and  six  toes  on  both  right  and  left  sides.  The  father  had 
six  toes  on  each  foot,  but  his  hands  Avere  normal.  One  brother  of  the 
father  has  polydactylism  of  hands  and  feet.  Four  other  brothers  of  the 
father  Avere  normal.  Tavo  of  them  Avere  married  and  their  children  Avere 
normal.  This  child  is  the  sixth  and  last.  Both  the  first  and  second  of  the 
children,  boys,  had  six  fingers  and  six  toes  on  each  side.  The  third  child, 
a  boy,  had  six  toes  on  one  foot,  otherAvise  Avas  normal.  The  fifth  child, 
a  girl,  Avas  normal. 

The  deformity  in  the  second  case  is  unusual:  the  right  hand  has  a 
double  thumb  with  double  metacarpal  bones,  and  is  Avebbed  completel}^, 
but  has  only  one  nail.  The  first  finger  is  rudimentary  throughout,  and  has 
no  power  of  flexion  or  extension.  The  second  and  third  fingers  are  fully 
dcA'eloped,  but  are  Avebbed  completely;  the  fourth  finger  is  normal.  The 
prehensile  poAver  of  the  hand  is  good,  and  no  operative  measures  are 
adA^sed  (Fig.  6). 

The  third  case  is  an  example  of  the  simplest  form  of  the  deformity. 
The  other  members  of  the  family  Avere  normal,  as  far  as  Avas  knoAvn ;  the 
extra  finger,  a  poorly  developed  terminal  phalanx,  with  its  nail,  Avas 
attached  by  a  long,  narroAV  pedicle  to  the  proximal  phalanx  of  the  little 
finger  of  the  left  hand  (Fig.  3). 

A  number  of  the  other  cases  presented  deformities  similar  to  those 
already  shoAvn. 

Adactylisin. — Suppression  of  both  fingers  and  toes. 

Kight  hand:  thumb,  metacarpo-phalangeal  joint  malformed ;  phalanges 
slightly  adducted ;  index  and  second  fingers  absent  beyond  the  metacarpo- 
phalangeal joint;  little  finger  normal;  third  finger  is  flexed  and  adducted 
at  the  joint,  betAveen  second  and  third  phalanges  (Fig.  1). 

Left  hand:  thumb  normal;  first  finger  lacks  first  and  second  phalanges; 
second  and  third  fingers  av ebbed  completely;  tAvo  bones  and  two  nails; 
fourth  finger  normal  (Fig.  8). 

Right  foot :  great  toe  adducted ;  second  and  third  toes,  including  corres- 
ponding metatarsal  bones,  absent;  fourth  and  fifth  metatarsal  bones  present, 
but  only  one  toe,  Avhich  seems  to  be  the  fifth,  and  this  articulates  Avith  the 
fifth  metatarsal  (Fig.  9). 

Left  foot:  same  deformity  as  in  the  right  foot,  but  in  this  case  it  seems 
to  be  the  fourth  toe  which  is  present,  and  this  articulates  Avith  the  fourth 
metatarsal.  The  parents  say  that  the  umbilical  cord  was  found  passing 
over  the  points  marked  "  x,"  but  this  explanation  is  probably  incorrect,  as 


322  REPORT   OF   THE   SOCIETY   OF   THE   LYIXG-IN   HOSPITAL. 

most  authorities  now  thinlc  these  deformities  are  dependent  upon  changes 
in  the  embryonal  cell  mass  (Fig.  10). 

TorticoUtK. — Two  of  the  cases  of  torticollis  illustrate  different  ways  in 
which  this  tleforniity  may  originate.  In  the  lirst  case  the  deformity  was 
notetl  a  few  hom*s  after  birth  and  for  the  next  two  days.  I  saw  the  child 
three  and  a  lialf  days  after  birth,  and  there  was  then  no  deformity  of  any 
kijuh  nor  anv  induration  in  the  muscles  of  the  neck.  This  is  interesting, 
as  congenital  torticollis  is  genei'ally  believed  due  to  an  actual  shortening  of 
tlie  sternocleido  mastoid,  and  cases  where  the  deformity  is  seen  just  after 
birth  are  commonly  ascribed  to  the  irritation  of  an  ha^matoma  in  that 
muscle,  caused  by  some  traumatism  received  at  birth.  In  this  case  it 
would  a]>}iear  to  have  been  due  to  a  temporary  ])aralysis  of  the  muscles 
on  one  side  of  the  neck,  allowing  their  opponents  to  incline  the  head  in  the 
opjMDsite  direction. 

The  second  case  was  a  breech  presentation.  Xo  deformity  was  noted 
at  birth.  A  tumor  was  first  seen  fourteen  days  afterwards  in  the  sterno- 
cleido nuistoid  on  the  right  side,  at  the  junction  of  the  middle  and  u])per 
thirds  of  the  muscle;  the  head  could  be  inclined  to  the  left  normally, 
but  the  rotation  of  the  chin  to  the  right  was  less  by  30  than  on  the  oppo- 
site side.  This  case  under  massage  and  manual  correction  steadily  improved, 
and  both  the  haematoma  and  the  deformity  entirely  disappeared  in  a  few 
months'  time. 

JL(r>  L'q). — One  simple  case  with  cleft  on  left  side,  involving  soft  parts 
only,  Avas  operated  upcju  with  excellent  result.  The  stitches  were  removed 
in  five  days;  union  Avas  ap})arently  complete,  but  during  some  violent  fits 
of  crying  the  Avound  was  torn  open.  A  secondary  operation  secured  a  very 
fair  result. 

In  a  second  case  there  was  a  douljle  maxillary  cleft  and  eversion  of 
pnemaxillary  Ijone.  The  hard  and  soft  palate  were  also  completely  cleft. 
The  child  was  ])uny,  l)ut  was  able  to  nurse.  She  was  when  last  seen  three 
months  of  age,  but  not  in  a  condition  to  undergo  the  radical  operation 
indicated. 

I  I  ndiinenUmj  Tail. — This  girl  when  she  was  four  weeks  old  presented 
the  appearance  roughly  shown  in  the  sketch;  this,  however,  accui'ately 
indicates  the  i-elative  i)Osition  and  extent  of  the  folds  in  the  gluteal  region 
and  tlie  thighs,  A  tail-like  process,  1^  inches  long,  with  a  slight  indenta- 
tion at  its  extremity,  was  attached  to  the  gluteal  region  about  1^  inches  to 
the  riglit  of  tlie  central  gluteal  crease.  This  Avas  excised  two  weeks  later 
and  was  found  to  be  a  mass  of  fibrous  and  fatty  tissue  attached  to  the 
])eriosteum  covering  the  end  of  the  coccyx,  which  was  itself  deflected  to  a 
]»osition  at  riglit  angles  with  the  last  segment  of  the  sacrum,  and  at  this 
]K»int  there  wjus  abnormally  free  movement.  The  anus  was  situated  in  the 
deep  fold  immediately  lielow  this  tail-like  process,  apparently  \\  inches  to 
right  of  median  line.  The  seconchiry  gluteal  fold  on  the  right  side.  l)elo\v 
the  fold  just  mentioned,  was  of  (-(lual  (l<'i)tli  and  extent  witli  the  latei'wl  gluteal 
crease  on  the  left  side,  as  shown  in  the  sketch,  ;iii<l  was  on  the  same  hori- 
zontal |»lane.     Tln-re  were  noother  ahnonnalitics  noted  in  this  case  (Fig.  11.) 


Fig.  I. 


Fig.2. 


K'^ 


Fic/.3. 


> 


X 


Flg.4. 


Flg.5. 


Flg.S. 


Fig,  9. 


Flg.lO. 


FigJL 


KEPORT   OF   ORTHOPAEDIC   SURGEON.  323 

Many  of  the  severest  cases  of  deformity,  such  as  hydrocephalus,  mon- 
sters, etc.,  were  still-born. 

Club  Foot. — Immediately  after  birth  the  physician,  as  a  matter  of  rou- 
tine treatment,  instructed  the  mother  or  attendant  how  to  manipulate  the 
feet  so  as  to  reduce  the  deformity  as  completely  as  possible.  She  was  told 
to  do  this  at  certain  regular  intervals,  and  was  also  shown  how  to  apply 
bandages  to  them  when  that  was  necessary.  In  the  more  severe  grades  of 
the  deformity  simple  retention  splints  were  applied  within  a  few  days  after 
confinement.  The  first  object  was  to  overcome  the  varus.  For  this  pur- 
pose a  light  steel  bar  with  cross-pieces  at  its  extremities  to  embrace  the  toes 
and  the  calf  of  the  leg  Avas  strapped  to  the  inside  of  the  leg  and  foot  after 
being  pro])erly  padded.  This  brace  was  put  on  the  foot  in  its  deformed 
position  and  gradually  straightened,  a  change  being  made  every  two  or 
three  days,  until  the  foot  was  brought  into  a  valgus  position.  The  equinus 
was  then  corrected  by  manipulation,  or  by  applying  a  brace,  similar  to  that 
described,  to  the  back  of  the  leg  and  sole  of  the  foot,  direct  pressure  back- 
wards being  applied  at  the  ankle  by  adhesive  plaster.  The  brace  was 
applied  in  the  position  of  deformity,  as  before,  and  the  foot-piece  gradu- 
allv  brought  up  to  a  right  angle  with  the  leg-piece.  Owing  to  the  very 
early  age  at  which  treatment  was  begun,  tenotomies  were  rarely  neces- 
sary. Eelapse  is  almost  sure  to  follow,  however,  unless  a  correct  position 
or  over-correct  position  of  the  foot  is  carefully  maintained  for  at  least  a 
year.  Daily  exercise  to  strengthen  weak  muscles  must  also  be  carried  out 
methodically  in  all  these  cases. 


21 


('oxTrjp.rxiox  to  the  topographical  anatomy  of 

THE    THOKAX    IX    THE    F(ETUS   AT    TEEM    AXD    THE 
XEW-BORX  CHILD. 

By  George  S.  Huntington,  M.D. 


Thk  following  anatomical  conditions,  aside  from  those  comiected  with 
the  circulatory  ai)paratus  and  dependent  upon  the  placental  type  of  respira- 
tion, imi)ress  their  character  most  strongly  on  the  arrangement  of  the 
viscera  in  the  foetal  thorax,  when  contrasted  with  the  form  and  contents  of 
the  adult  chest  cavity. 

1.  Ditferences  in  extent  and  configuration  of  the  lungs  before  and 
after  ])ulmonary  respiration  has  been  established. 

2.  Ditferences  in  the  extent  of  the  })leural  sacs  and  of  the  complemen- 
tary pleural  spaces,  especially  the  costophrenic  sinus. 

3.  Presence  of  the  thymus  gland. 

4.  Relative  large  size  of  the  foetal  liver,  influencing  indirectly  the 
arrangement  of  the  thoracic  contents  l)y  determining  tlie  level  of  the  dia- 
)»liragin. 

Tlie  following  nuMiioranda  have  been  ct^mpiled  tVom  tlie  examination  of 
the  thorax  and  its  contents  in  five  foetus  at  term,  four  newly-born  infants 
who  died  witlnn  a  few  hours  after  birth,  and  two  foetus  of  25  and  31 
weeks  (estimated)  res))ectively. 

The  material  has  in  all  cases  been  prepared  by  the  pvclimiiiarv  injection 
through  tlie  umbilical  vein  of  a  ten  per  cent,  formaline  solution,  at  a  hydro- 
stiitic  pressure  varying  from  one  to  three  feet.  This  hardening  fluid  pos- 
sesses jMjculiar  value  for  the  determination  of  the  topographical  relations 
of  the  l>o(ly  cavities  .and  viscera.  In  the  strength  above  indicated  the 
(jedematous  swelling  at  times  observed  with  the  use  of  weaker  solutions  is 
entirely  conlinwl  to  the  subcutaneous  connective  tissues.  The  deeper  ])arts, 
es|>ecial]y  tlie  viscera,  are  hardened  ///  .ntn  in  such  a  manner  as  to  ])reserve, 
even  whon  removed  from  the  body,  their  correct  form,  and  to  indicate  most 
accuratoly  by  the  surface;  markings  their  natural  relationshii)  to  surround- 
ing structures.  The  solution  is  eminently  well  adapted  to  the  complete 
hardening  and  ])reservation  of  the  lung.  The  viscus  appears  of  almost 
rubber-like  consisteney,  and  admits  fi-eely  of  manipulation,  without  the 
least  impairment  of  ihc  normal  sli:ipe.  iind  without  disturbing  the  relations 


ANATOMY    OF   THE   THORAX    IN    THE    FCETUS    AT   TERM,    ETC.  325 

to  surrounding  structures.  The  preparations  which  can  be  obtained  by  this 
method  are  of  the  greatest  value  in  determining  the  topography  of  the 
tlioracic  cavity.  More  especially  is  it  possible  by  their  aid  to  deal  with 
the  mutual  relations  of  the  lungs  and  mediastinal  contents  from  an  entirely 
novel  point  of  view.  The  hardened  lung  reflects  accurateh'  its  relation  to 
the  thoracic  parietes  and  to  the  structures  contained  in  the  mediastinum. 

It  is  especially  desirable  to  formulate  a  precise  description  of  the  thor- 
acic organs  in  the  foetus  for  comparison  with  the  same  structures  in  the 
adult.*  In  the  following  communication  this  attempt  has  been  made,  and 
although  the  material  is  not  large,  yet  the  uniform  disposition  of  the  more 
important  structures  in  all  the  preparations  examined  affords  good  ground 
for  regarding  the  conditions  described  as  conforming  to  the  normal  type. 

The  lungs  of  the  foetus  and  new-born  infant  are  free  from  the  disturb- 
ing influences  which  in  later  life  pulmonary  disease  so  frequently  exerts  on 
the  disposition  of  the  thoracic  organs.  For  this  reason  the  study  of  foetal 
material  possesses  a  special  value  in  the  regions  in  question. 

The  subject  matter  of  these  observ^ations  may  be  arranged  under  the  fol- 
lowing headings: 

I.  Form  and  External  Characters  oe  the  Lungs. 

A.  Surfaces  of  the  Lungs. 

Each  lung  presents  four  surfaces — -the  viscus  having  the  form  of  a  trun- 
cated pyramid,  with  three  unequally  develooed  lateral  surfaces  converging 
to  a  blunt  apex,  the  fourth  surface  forming  the  broad  base  by  means  of 
which  the  organ  rests  on  the  convex  upper  surface  of  the  diaphragm. 

The  general  disposition  of  the  side  and  basal  surfaces  is  best  obtained  by 
examining  the  hardened  lungs  of  a  foetus  in  the  later  months. 

Figs.  I  to  lY  present  the  medial  and  lateral  aspects  of  the  right  and 
left  lungs  of  a  foetus  esthnated  to  be  in  the  twenty-fifth  week,  and  Figs.  Y 
and  YI  give  outline  representations  of  the  basal  or  phrenic  surfaces  of  the 
same  lungs. 

The  sharp  anterior  margin  (Figs.  Y  and  YI,  2)  admits  readily  of  the 
usual  division  into  a  lateral  or  sternocostal  convex,  and  a  medial  or  medi- 
astinal concave  surface. 

AVhile  this  sharp  differentiation  exists  along  the  entire  well-defined 
anterior  margin  of  the  lung,  the  arrangement  of  the  posterior  thick  portion 
presents,  in  the  organ  detached  and  removed  from  the  bodj^,  greater  diffi- 
culties. The  correct  appreciation  of  this  portion  of  the  lung  depends  U23on 
exact  reference  to  the  mediastinal  structures  and  to  the  part  of  the  thoracic 
wall  with  which  the  same  comes  into  contact. 

The  examination  of  the  basal  outlines  of  these  foetal  lungs  shows  that 

*  While  this  paper  was  in  press,  Dr.  J.  A.  Blake,  of  Columbia  University,  pre- 
sented the  results  of  similar  investigations  of  the  adult  thorax  to  the  Association  of 
American  Anatomists  at  Washington  in  May  of  this  year.  His  pa^jer  will  be  pub- 
lished in  the  Proceedings  of  the  Ninth  Annual  Meeting  of  the  Association,  and  will 
form  a  very  valuable  sequel  to  the  present  communication. 


336  REPORT  OF  THE   SOCIETY   OF   THE   LYING-IN   HOSPITAL. 

each  presents  u  east  of  its  side  of  the  thoracic  cavity.  The  following  sur- 
faces cau  be  distinguished: 

1.  S^entOi'Ofifd/  ifinfare  (Figs.  V  and  YI,  1)  extends  transversely  between 
the  sharp  anterior  margin  (2)  and  the  blunt  posterior  margin  (0),  fitted 
against  the  concavity  of  the  parietal  i>leura  lining  tlie  internal  surface  of 
the  thoracic  wall  from  the  posterior  surface  of  sternum  and  costal  cartilages 
in  front  to  the  line  marked  superficially  by  the  costal  angles  behind. 

1'.  Muliasiiiml  surface  (Figs.  Y  and  YI,  3)  is  included  between  the 
anterior  (2)  and  internal  margin  (4),  concave  in  main,  directed  inward  and 
somewhat  forward  in  the  posterior  part,  modelled  upon  the  contents  of 
the  anterior  ])()rtion  of  the  mediastinum,  es})ecially  upon  portions  of  the 
l^ericardium.  thymus  gland,  and  large  vessels  covered  by  the  mediastinal 
pleura. 

3.  Costovertehral  surface  (Figs.  Y  and  YI,  5)  directed  })ack wards  and 
inwards,  included  between  the  internal  (4)  and  posterior  borders  {(\).  This 
surface  is  a])plied  to  that  portion  of  the  parietal  pleura  which  covers  the 
sides  of  the  vertebral  bodies  and  intervertebral  disks,  the  heads  of  the  ribs 
and  symjmthetic  nerve  strand,  and  the  anterior  surface  of  the  necks  and 
])odios  of  the  ribs  as  far  out  as  tlic  ])oint  -wliere  the  latter  change  their 
orijrinal  outward  and  backward  direction  to  curve  forward  in  the  lateral 
thoracic  wall. 

Tlie  principle  adopted  in  the  above  definition  of  the  lung  surfaces  is 
afforded  by  the  direction  of  the  surfaces,  the  presence  of  distinct  margins, 
and  the  relations  to  thoracic  contents  and  walls.  The  mediastinal  surface 
is  taken  to  include  all  that  portion  of  the  medial  aspect  of  each  lung  which 
comes  indirectly,  by  means  of  the  interposed  mediastinal  layer  of  the  parie- 
tal pleura,  into  contact  and  relation  with  the  visceral,  vascular,  and  ner- 
vous structures  contained  in  the  mediastinal  space.  This  is  quite  readily 
apparent  in  the  anterior  ]mrts  of  this  surface,  where  large  impressions  exist 
for  adai)tation  to  tlie  bulky  thymus  gland  and  pericardium.  In  the  pos- 
terior portion  of  this  area  the  relation  to  structures  entering  and  lea^'ing 
the  lung  at  the  hilus  is  well  defined,  from  the  intimate  connection  of  these 
parts  with  the  j)ulmonary  substance.  But  above,  below,  and  behind  the 
hilus  the  mediastinal  surface  of  the  lung  comes  into  contact  with  the  pleura 
covering  va.scular  and  visceral  sti'uctures  which  })ursuo  in  main  a  vertical 
coui*se  in  the  posterior  mediastinum. 

The  publislied  descriptions  of  the  anatoni}'  of  tlu;  lung  separate  a  sterno- 
c<:;sta]  and  mediastinal  surface  by  the  sharj)  anterior  margin,  and  state  in 
general  that  j)osteriorlv  these  pass  into  each  other  by  means  of  a  thick, 
rounded  posterior  border.  Even  to  take  the  posterior  margin  of  the  aortic 
groove  as  separating  tlif  nu-diastinal  from  the  parietal  surface  of  the  left 
lung,  and  the  jjosterior  margin  of  the  azygos  furrow  as  sejmrating  the  cor- 
responding j)ortions  of  the  right  lung,  is  not  correct.  In  the  detailed  con- 
.siileration  of  the  relations  of  the  mediastinal  |)iiliiionarv  surfaces,  given 
l>elow,  it  will  be  .seen  that  the  character  of  this  aica  is  eomj)lex,  coming  into 
relation  with  successive  structures  as  liny  a|)i)roach  or  recede  from  the 
poslf-rior  part  of  tin-  inrdinstinal  plciiral  leaf. 


ANATOMY    OF    THE    THOHAX    IX    T]1E    FQ'n'L'S    AT    TERM,    ETC.  327 

It  seems,  therefore,  more  in  accordance  with  the  actual  conditions  to 
define  the  mediastinal  surface  as  including  that  portion  of  the  lung  which 
is  in  relation  with  the  mediastinal  })leural  reflection  covering  the  vascular, 
glandular,  visceral,  and  nervous  structures  of  the  mediastinal  space. 

This  area  is  separated  by  wdiat  we  have  termed  the  "  internal "  margin 
from  the  surface  in  contact  with  the  parietal  pleura  investing  the  walls  of 
the  thoracic  cavity.  This  internal  margin,  varying  in  distinctness  in  differ- 
ent parts  of  its  extent,  is,  therefore,  the  composite  of  the  successive  posterior 
borders  of  a  series  of  impressions  which  result  from  the  relation  of  this 
portion  of  the  lung  to  the  pleura  investing  the  longitudinal  vascular  and 
visceral  contents  of  the.  posterior  part  of  the  mediastinal  space.  The 
details  of  this  margin  will  be  subsequently  considered. 

The  surface  of  the  lung  in  contact  with  the  pleura  covering  the  thoracic 
parietes  is  generally  convex,  and  in  the  foetal  lung  is  quite  evidently  divided 
into  a  lateral  or  sternocostal^  ^Jidi  posteromedial  or  costovertebral  surface. 

The  sternocostal  surface  is  limited  anteriorly  by  the  sharp  anterior  mar- 
gin, in  w^hich  it  meets  the  mediastinal  surface.  The  posterior  limit  is 
afforded  by  a  rounded  but  distinct  border  (Figs.  Y  and  VI,  6),  which  fits 
into  the  vertical  groove  formed  by  the  succession  of  ribs  and  intercostal 
spaces  at  the  point  where  the  former  change  their  original  outward  and 
backward  direction  to  turn  forward  in  conformity  with  the  lateral  curve  of 
the  thoracic  wall. 

The  costovertebral  s'wrface  extends  between  this  posterior  border  and 
the  internal  margin,  as  above  defi.ned.  As  the  name  proposed  indicates, 
this  surface  comes  into  relation  with  the  parietal  pleura  covering  the  lateral 
aspects  of  the  vertebral  centres  and  disks  and  the  portions  of  the  ribs  and 
intercostal  spaces  which  extend  between  the  costovertebral  line  of  articula- 
tion and  the  line  indicated  superficially  by  the  succession  of  the  costal  angles. 

B.  Changes  in  External  Form  During  the  Later  Developmental  Stages 
of  the  Lungs. 

In  the  earlier  stages  of  development  the  posterior  border  is  sharper, 
and  the  costovertebral  surface  is  directed  obliquely  backward  and  inward 
(Figs.  V  and  YI).  As  the  lung  develops,  the  increase  in  size  affects  pri- 
marily the  posterior  portions. 

Figs.  YII  to  XII  present  the  lateral  and  medial  aspects  and  the  out- 
lines of  the  basal  surfaces  of  the  right  and  left  lungs  of  a  foetus  of  thirty- 
one  weeks  (estimated). 

It  will  be  noted  (Figs.  XI  and  XII,  6)  that  the  posterior  margin  is 
more  rounded,  and  that  the  costovertebral  surface  looks  almost  directly 
inwards  (Figs.  XI  and  XII,  5).  This  change  in  direction  produces  a 
diminution  in  the  distinctness  of  the  internal  margin  (Figs.  XI  and  XII, 
4)  as  seen  from  the  basal  surface,  since  the  costovertebral  surface  forms  a 
more  direct  continuation  backwards  of  that  part  of  the  mediastinal  surface 
which  is  in  relation  with  the  vertical  structures  occupying  the  posterior 
mediastinal  space.  At  the  same  time  it  will  be  presently  seen  that  the 
differentiation  of  the  two  surfaces,  as  indicated  by  the  impressions  pro- 
duced, becomes  more  marked  with  the  full  development  of  the  lung. 


328  REPORT  OF  THE  SOCIETY    OF  THE    LVINO-IX    HOSPITAL. 

Kig.  XI 11  represents  the  basal  aspect  of  the  lungs  of  a  foetus  at  term, 
together  with  the  inferior  surface  of  the  ))ericarclium  and  attached  portion 
of  the  diapliragin.     The  same  relative  chanues  are  t(^  l)e  noted  here. 

The ///</'</</(•  or  baf<a/  i>-n/;f(/i'i'  of  both  lungs  is  uniformly  concave,  moulded 
over  the  convexity  of  the  diaphragmatic  cupolae.  The  varying  propor- 
tions in  which  the  different  lol)es  contribute  to  the  formation  of  this  sur- 
face will  be  considered  in  speaking  of  the  course  of  the  nuiin  interlobar 
incisures. 

C  Ju-femal  l^ornt^  Fissures,  Incisures,  and  Lohes. 

The  com})arison  of  the  foetal  lung  in  the  earlier  stages  with  the  fully 
develoj)etl  organ  at  term  shows  some  characteristic  changes  in  form. 

1.  Lift  Lutuj. 

The  lung  rejiresented  in  Figs.  Ill  and  IV  (25  weeks,  estimated)  gives 
the  following  picture: 

Elongated,  cone-shaped,  the  sternocostal,  costovertebral  and  medias- 
tinal surfaces  narrowing  uniformly  and  gradually  to  the  apex,  which  pre- 
sents a  smooth,  rounded  lateral  and  slightly  concave  medial  surface. 

A  slight  dei)ression  (Figs.  Ill  and  lY,  2),  differentiating  the  apex 
])roper  from  the  posterior  border,  is  produced  by  the  proximal  portion  of  the 
anterior  margin  of  the  first  rib.  The  anterior  margin  shows  a  similar 
though  slighter  costal  impression  (Figs.  Ill  and  IV,  3),  separating  it 
from  the  apex. 

The  anterior  margin  appears  crenated  by  a  number  of  short  incisures. 
One  of  these,  the  anterior  marginal  incisure*  (Figs.  Ill  and  IV,  4), 
extends  somewhat  more  deeply  upward  and  l)ackward  on  the  medial  sur- 
face. A  second  more  deeply  marked  incisure  (Figs.  Ill  and  IV,  5) 
api)eai's  to  foreshadow  the  development  of  the  typical  cardiac  curve. 
Tliese  secondary  fissures  represent  rudiments  of  the  occasional  additional 
lissure  which  in  the  adult  at  times  extends  backward  from  the  deepest 
portion  of  the  cardiac  incisure  to  meet,  in  extreme  cases,  the  main  inter- 
lol>ar  incisure,  and  thus  re])eat  the  intermediate  fissure  of  the  right  lung. 

The  lung  shown  in  Figs.  IX  and  X  (31  weeks,  estimated)  exhibits, 
when  contrasted  with  the  preceding,  the  tyi)ical  changes  occurring  in  the 
further  development  of  the  organ.  The  most  notal^le  difference  exists  in 
the  up])or  and  apical  ])ortions  of  the  lung.  The  site  of  the  original  rounded 
blunt  apex  of  the  cone  is  still  discernible,  Ijotli  the  posterior  and  anterior 
margins  exhibiting  the  first  costal  impression  (Figs.  IX  and  X,  2,  8). 

The  anterior  marginal  fissure  (Figs.  IX  and  X,  4)  is  well  marked  on 
l>oth  the  lateral  an<l  medial  sui-faces.  TIk;  extent  of  the  U])])ei-  lobe,  mcas- 
urwl  along  the  anterior  margin  between  8  and  4,  and  along  the  ])osterior 
border  b<;tween  2  and  the  intersection  of  the  main  intei-lobar  incisui-e, 
indicates  a  very  marked  antero-|)osterior  ex})aiision  of  this  portion  of  the 
lung. 

•  It  has  been  considered  advis.-ihlf  to  (lcsi;,''ii:itc  lliis  lissm-c  of  the  left  Iiiii^'' l)y  a 
Rpeciul  U-rm.  on  ar<'oinit  «»f  its  constaiit  occunM-ncc  in  I  lie  cirlici-  stages  and  {\n\  \r.\Yi  it 
plavH  in  tli(>  jjrrKlurtioii  of  tin;  in«»ro  important  lissui-al  variations  of  the  left  lung'  iu 
the  later  Hluges. 


ANATOMY   OF   THE    THORAX    IN   THE    FCETUS    AT   TERM,    ETC.  329 

In  the  earlier  stages  (Figs.  Ill  and  IV)  the  anterior  margin  slopes 
uniformly  and  gradually  downward  and  forward  from  the  apex  to  the 
anterior  marginal  fissure  (4),  at  an  angle  of  about  45  degrees  with  the  ver- 
tical long  axis  of  the  })Osterior  border.  In  Figs.  IX  and  X  the  same  por- 
tion of  the  anterior  margin  in  the  older  lungs  is  seen  to  pass  at  first  for- 
ward from  the  apex,  nearly  at  right  angles  with  the  line  of  the  posterior 
border.  It  then  abruptly  turns  downward,  and  recedes  somewhat  to  the 
beginning  of  the  anterior  marginal  fissure  (4),  developing  a  blunt,  nearly 
quadrangular  superior  marginal  process,  which  overhangs  the  cardiac 
incisure  from  above. 

Below,  the  lingula  is  also  produced  forward  and  inward,  resulting  in 
the  hook-like  inferior  limit  of  the  cardiac  incisure.  The  formation  of  the 
wide  cardiac  incisure  is  chiefly  to  be  credited  to  the  forward  expansion  of 
the  anterior  portion  of  the  upper  lobe,  between  the  apex  and  the  anterior 
marginal  fissure.  The  anterior  margin  of  the  lung  in  the  region  of  the 
cardiac  incisure  presents  the  same  crenated  appearance,  although  the  fis- 
sures and  indentations  are  relativel}^  smaller  and  of  less  depth  than  in  the 
first  lung. 

The  changes  affecting  the  loAver  lobe  are  best  appreciated  by  considering 
the  course  of  the  main  interlobar  incisure,  the  extent  of  the  medial  surface 
of  the  inferior  lobe,  and  the  position  of  the  hilus. 

In  the  first  lung  (Fig.  IV)  the  main  interlobar  incisure  runs  a  much 
ra.ore  vertical  course  on  the  sternocostal  surface.  Fig.  IX  indicates  by 
the  more  oblique  course  of  this  fissure  that  in  the  later  stages  the  growth 
has  involved  more  especially  the  anterior  and  lateral  portions  of  the  infe- 
rior lobe,  resulting  in  a  sagittal  increase  of  the  lower  portion  of  the 
sternocostal  surface.  Coincident  with  this,  the  relative  extent  of  the 
inferior  lobe  on  the  mediastinal  surface  is  less.  In  the  earlier  lung  (Fig. 
Ill)  the  mediastinal  surface  of  the  lower  lobe  presents  a  broad  triangular 
area,  forming  approximately  one-third  of  the  entire  mediastinal  surface, 
between  the  main  interlobar  incisure,  the  line  of  attachment  of  the  lio-a- 
mentum  latum,  and  the  medial  margin  of  the  phrenic  surface.  In  the  later 
stage  this  area  is  reduced  in  extent,  but  much  more  prominent,  forming 
(Fig.  X)  a  sharp  triangular  process  (pericardio-cesophageal  tuberosity),  to 
be  subsequently  considered  in  detail  with  the  topographical  relations  of  this 
surface.  It  is,  however,  to  be  remembered  that  individual  variations  in  the 
arrangement  of  the  main  fissures  and  incisures  are  not  infrequent.  (See 
below.)  As  already  stated,  reference  to  the  outline  tracing  of  the  phrenic 
surface  (Figs.  VI  and  XII)  shows  an  expansion  and  rounding  of  the 
posterior  margin  and  a  more  sagittal  direction  of  the  costovertebral  sur- 
face. 

The  uncinate  character  of  the  lingular  process,  curving  forward  and 
inward,  is  also  to  be  noted  in  comparing  the  basal  surface  of  the  second 
with  that  of  the  earlier  lung. 

The  aortic  groove  becomes  much  more  distinct  in  the  later  stage,  and 
in  the  view  of  the  medial  aspect  (Fig.  X)  the  beginning  of  the  costover- 
tebral surface  dorsal  to  the  groove  is  to  be  observed. 


330  REPORT  OF  THE   SOCIETY   OF   THE    LYING-IN   HOSPITAL. 

The  liilus  «»f  the  more  lulvaiiced  lung  occupies  a  relatively  greater  area 
on  tlie  meiliastinal  surface.  This  is  more  esjiecially  marked  in  the  inferior 
|K>rtion.  i*esulting  in  a  shortening  of  tlie  ligamentnm  latum. 

In  the  further  (levelo])ment  of  the  external  form  of  the  left  lung  the 
clianges  inclicatetl  above  lead  to  the  establishment  of  two  quite  distinct 
ty])es. 

Instances  of  these  are  given  in  Figs.  XIV  to  XVII,  representing  the 
sterno<.'ostal  and  mediastinal  surfaces  of  two  left  lungs  at  term. 

T>ij>e  1.  Luinj  u'ltli  irrll-<leveloj)ed  cardiac  incisui'e  (Figs.  XIV,  XV, 
and  XVIin. 

The  quadrangular  form,  noted  as  appearing  in  IX  and  X,  is  here  still 
further  develo])ed,  due  to  the  great  antero-posterior  extent  of  the  supe- 
rior lobe  and  marked  development  of  the  anterior  portion  of  the  same 
above  the  cardiac  incisure.  The  quadrangular  marginal  process  forming 
the  up))er  limit  of  the  latter  is  especially  prominent. 

The  anterior  marginal  fissure  is  present  and  distinct,  appearing  both  on 
the  sternocostal  and  metliastinal  surfaces. 

The  cardiac  incisure  is  deep,  forming  three  sides  of  a  rectangle,  bounded 
below  by  the  prominent  incurve  of  the  hook-like  lingula. 

The  main  interlobar  incisure  on  the  sternocostal  surface  meets  the 
inferior  margin  at  a  point  which  would  correspond  to  the  vertical  prolonga- 
tion down^vard,  across  the  root  of  the  lingula,  of  the  bottom  of  the  cardiac 
incisure. 

On  the  mediastinal  surface  the  inferior  lobe  presents  an  extensive  area. 
The  course  of  the  main  interloljar  incisure,  in  returning  to  the  anterior 
margin  of  the  hilus,  on  the  mediastinal  surface,  follows  the  type  indicated  in 
the  earlier  stages  in  Fig.  III.  The  incisure  meets  the  anterior  border  of 
the  hilus  nearly  at  the  middle,  and  a  large  triangular  area,  belonging  to 
the  mediastinal  aspect  of  the  inferior  lobe,  presents  in  its  anterior  and  larger 
part  a  concavity  iav  adajitation  to  the  left  sui'face  of  the  pericardium,  its 
smaller  posterior  and  inferior  segment  forming  the  prominent  triangular 
tt'sophageal  surface. 

Ti/jn-  2.  Ahi«'/ifi'  of  cardiac  incisure.  Assimilation  of  external  form,  to 
that  of  ri'jlif  I II ml. 

In  strong  conti-adistinction  to  the  ])reccding  form  is  the  superficial  con- 
figuration of  tlie  lung  shown  in  Figs.  XVI  and  XVII. 

The  entire  a])pearance  of  the  lung  suggests  the  structure  usually  encoun- 
tered on  tlie  right  side.  The  anterior  margin  is  nearly  vertical.  There  is 
no  cardiac  incisure.  The  anterior  marginal  fissure  is  well  developed  and 
crr>s.sf?s  the  sternocostal  surface  so  as  to  nearly  intersect  the  main  inter- 
lobar incisure.  The  anterior  mai^gin  turns  with  an  obtuse  angle  into  the 
8U|KTior  division,  sloping  slightly  upward  and  backward  to  the  apex. 

The  u])per  lolje,  compared  with  the  first  type,  is  slightly  less  Cjuadran- 
gular.  Possibly  tlie  abr.ence  of  the  cardiac  incisure,  and  the  consetpient 
increase  in  lung  substance  along  the  anterior  and  inferior  marginal  por- 
tions of  the  lung,  accounts  for  the  somewhat  smaller  sagittal  extent  of  the 
upjKjr  part  of  the  su])erior  lobe. 


ANATOMY    OF   THE   THORAX    IN    THE    FCETUS   AT   TERM.    ETC.  331 

The  middle  lobe,  which  is  thus  marked  out  on  the  sternocostal  surface, 
evidently  corresponds  to  a  very  highly  developed  lingula. 

On  the  mediastinal  surface  the  main  interlobar  incisure  follows  the 
course  indicated  previously  in  Fig.  X.  It  does  not  quite  reach  the  inferior 
part  of  the  anterior  hilus  margin.  The  mediastinal  surface  of  the  inferior 
lobe  is  confined  to  the  strongly  developed  triangular  pericardio-oesophageal 
tuberosity. 

The  anterior  marginal  fissure  penetrates  on  the  mediastinal  surface 
backward  and  upward,  covering  two-thirds  of  the  distance  between  the 
anterior  lung-  maro;in  and  the  anterior  border  of  the  hilus. 

The  difference  in  the  conformation  of  the  left  lung  and  of  the  cardiac 
incisure  exhibited  by  the  above  types  appears  to  be  independent  of  the 
development  of  the  thymus  gland.  In  both  cases  a  well-developed  typical 
thymus  was  present.  The  large  size  and  pronounced  character  of  the 
cardiac  incisure  in  the  first  form  (Figs.  XIV  and  XY)  would  appear  to 
negative  the  view  expressed  by  some  authors,*  according  to  which  the  car- 
diac incisure  does  not  make  its  appearance  until  involution  of  the  thymus 
permits  of  greater  expansion  of  the  upper  portion  of  the  left  lung. 

2.  PdgU  Lung  (Figs.  I,  II,  Y,  YII,  YIII,  XI). 

The  right  lungs  of  the  two  younger  foetus  of  25  and  31  weeks  are 
represented  in  medial  and  lateral  views  and  in  projection  outline  of  the 
basal  surface  in  the  above  figures. 

The  differences  in  the  external  form  of  the  right  lung  in  the  earlier  and 
later  stage  are  of  the  same  character  as  on  the  left  side,  but  less  pro- 
nounced. The  right  lung  of  the  earlier  foetus  is  less  elongated  than  the  left 
lung  of  the  same  preparation,  the  greatest  sagittal  and  vertical  diameters 
being  more  nearly  equal. 

The  pointed  apical  portion  of  the  earlier  stages  (Figs.  I  and  II)  is, 
how^ever,  again  replaced  by  the  more  quadrangular  form  in  the  older  lung 
(Figs.  YII  and  YIII),  due  to  the  sagittal  expansion  of  the  upper  lobe. 
The  first  part  of  the  posterior  margin,  which  inclines  obliquely  back- 
ward and  downward  in  the  younger  specimen,  is  directed  almost  hori- 
zontally in  the  older  lung,  bringing  the  apex  more  into  direct  continua- 
tion with  the  anterior  margin.  Later,  at  term,  the  expansion  of  the  upper 
and  anterior  segment  of  the  superior  lobe  restores  the  apex  to  its  position 
as  the  upper  rounded  termination  of  the  posterior  margin  (Figs.  XIX, 
XX,  XXI,  XXII).  Between  the  apex  proper  and  the  beginning  of  the 
vertical  portion  of  the  anterior  margin,  a  superior  marginal  portion  passes 
forward  with  but  a  very  slight  downward  inclination  (Figs.  XIX  to  XXII). 
At  times,  apparently  after  pulmonary  respiration  has  been  inaugurated, 
the  beginning  of  the  vertical  portion  of  the  anterior  margin  is  marked  on 
the  mesal  aspect  by  a  prominent  rounded  tubercle,  w^hich  imparts  to  the 
superior  segment  of  the  marginal  portion,  between  it  and  the  apex,  a 
slight  concavity  upwards  (Fig.  XXIII,  above  3). 

A  number  of  variations  are  presented  in  the  arrangement  of  the  inter- 
lobar fissures  of  the  rio'ht  lung-. 

*  C.  Gegeiibauer,  Lelirb.  d.  Anat.  d.  Menschen,  1890,  Bd.  ii.,  p.  10-4. 


332  REPORT   OF   THE   SOCIETY   OF   THE    LYING-IX    JIOSriTAL. 

a.  Stt'rnoc('-'<f(d  sinface. 

(1)  The  typical  form,  which  corresponds  to  the  usual  achilt  condition,  is 
representeil  on  the  sternocostal  surface  by  Fig.  YII.  The  intermediate 
fissure  leaves  the  main  interlobar  incisure  at  an  acute  angle  and  passes  for- 
wartl  over  the  sternocostal  surface  to  the  anterior  margin,  its  direction 
being  nearly  parallel  to  the  course  of  the  anterior  part  of  the  inferior 
maririn.  The  outline  of  the  sternocostal  surface  of  the  middle  lobe  is 
nearly  that  of  a  ])arallelogram. 

(2)  In  a  second  form,  the  middle  portion  of  the  intermediate  fissure  is 
obliterated,  ])artially  or  completely  (Figs.  XYIII  and  XIX),  the  fissure 
developing  only  at  its  point  of  dei)ai'ture  from  the  main  interlobar  incisure, 
and  again  a  short  distance  from  the  anterior  margin. 

(3)  A  third  type  is  presented  by  the  extension  of  the  intermediate  fis- 
sure doi*sad  of  the  main  incisure  (Fig.  XXI).  At  times  this  is  combined 
with  island  formation  at  the  anterior  extremity  (Fig.  II). 

The  return  of  the  main  interlobar  incisure  of  the  right  lung  across  the 
lower  ]K)rtion  of  the  mediastinal  surface  again  presents  variations  which 
are  similar  to  those  encountered  on  the  left  side. 

The  usual  arrangement  is  indicated  in  Figs.  YIII,  XX,  XXII,  and 
XXIII.  The  termination  of  the  fissure  meets,  or  nearly  meets,  the  ante- 
rior inferior  margin  of  the  hilus,  defining  the  anterior  border  of  an  irregu- 
larly quadrangular  field  for  apposition  to  the  inferior  vena  cava  (XX, 
XXII,  XXIII,  1).  More  exceptionally  (Fig.  I)  the  fissure  returns  on 
the  mediastinal  surface  to  the  inferior  angle  of  the  hilus,  nearly  excluding 
the  inferior  lobe  from  ]XTrtici]iation  in  the  composition  of  the  mediastinal 
surface. 

The  intermediate  fissure  usually  appears  reduced  on  the  mediastinal  sur- 
face, rarely  reaching  as  far  as  the  anterior  border  of  the  hilus. 

Figs.  I,  XX,  and  XXIII  exhil)it  instances  of  this  limitation  of  the 
mediastinal  portion  of  the  intermediate  fissure.  Figs.  VIII  and  XXII 
afford  examples  of  the  more  extensive  develo])ment  of  this  fissure  on  the 
me<liastinal  surface.  The  beginning  of  the  main  interlobar  incisure  at 
times  traverses  the  azygos  groove  (Figs.  I  and  XX),  beginning  at  the 
upjKT  ])ostf'rior  border  of  the  hilus.  The  entire  ])osterior  segment  of  the 
fissure  is  complete,  travelling  l)ackwar(l  over  the  costovertebral  surface. 
In  other  instances  the  incisure,  beginning  at  the  same  point,  is  obliterated 
in  the  segment  crossing  the  costovertebral  surface  (Figs.  VIII,  XXIII). 
In  other  ca.ses  tiie  region  of  the  azygos  groove  is  not  fissured,  the  incisure 
first  apjxraring  on  the  costovertebral  surface  (Fig.  XXII). 

e.  Phrenlf  or  h<inti}  Hurfdrc. 

The  greater  area,  com])ared  with  the  Idt  side,  which  the  ])hrenic  sur- 
face of  the  right  lung  ])resents,  is  seen,  by  reference  to  Figs.  V,  XI,  and 
XIII,  tf)  be  mainly  <lue  to  the  greater  biis.-il  siiifncc  of  the  Y\<^\\i  middle,  as 
conipare<l  with  tiie  upper  left  lobe. 

In  the  earlier  stages  (V  and  VT)  the  basal  intci-loliiu'  incisure  passes  on 
both  sides  obli(iuelv  backwiiid   imd   inwiird  towjiid  the  nif(h';d  inarLnn  of 


ANATOMY    OF    THE   THORAX    IX    THE    F(ETUS   AT   TERM,    ETC.  333 

the  phrenic  surface.  In  tlie  okler  lung.s  (XI,  XII,  and  XIII)  the  direc- 
tion of  the  incisure  both  in  right  and  left  hmg  is  more  nearly  transverse. 

On  the  right  side  the  incisure  meets  the  mediastinal  border  of  the  phrenic 
surface  a  short  distance  behind  the  centre.  This  change  in  direction  is 
evidently  due  to  the  greater  area  of  contact  in  the  later  stages  between  the 
postero-internal  portion  of  the  right  lung  and  the  intrathoracic  segment 
of  the  inferior  vena  cava. 

Azygo^  lohe  and  fissure. 

At  times  the  median  and  posterior  portion  of  the  phrenic  surface  is 
more  or  less  completel}^  separated  from  the  rest  of  the  inferior  lobe  by  a 
fissure  or  set  of  fissures  defining  a  portion  of  the  lung  which  corresponds 
in  position  and  relation  to  the  inferior  cava  to  the  infracardiac  or  azygos 
lobe  of  lower  mammalia. 

Fig.  XXY,  1,  presents  a  sim])le  form  of  this  fissure  and  rudimentary 
lobe. 

In  the  lung  represented  in  Fig.  XXIY  a  more  complex  arrangement  of 
this  structure  exists. 

The  posterior  segment  of  the  fissure — beyond  2 — is  incomplete,  although 
it  can  be  traced  backwards  and  inwards  beneath  the  investing  visceral 
pleura. 

In  all  cases  the  anterior  portion  of  the  azygos  lobe  passes  forward, 
forming  a  blunt,  tongue-shaped  marginal  process  (Fig.  XXIY,  1)  which  at 
times  projects  some  distance  bej^ond  the  internal  portion  of  the  main  inter- 
lobar incisure,  resting  in  contact  wath  the  basal  surface  of  the  middle 
lobe. 

(The  foetus  D  and  G,  from  which  Figs.  XXIY  and  XXY  are  taken, 
Avere  twins,  both  female.) 

D.  Attacliment  of  Broad  Pidmonary  Ligament. 

1.  Bight  Lung  (Figs.  I,  YIII,  XX,   XXII,  XXIII,  8). 

The  pleural  fold  is  attached  to  the  ' '  lower  oesophageal  area ' '  {vide 
infra)  of  the  mediastinal  surface,  crossing  the  same  usually  somewhat 
obliquely  from  the  lower  angle  of  the  hilus  downward  and  backward. 

The  sharp,  somewhat  projecting  ridge  just  anterior  to  the  pulmonary 
attachment  of  the  fold  fits  into  the  angular  recess  between  oesophagus  and 
vena  cava. 

2.  Left  Lung  (Figs.  Ill,  X,  XY,  XYII,  1). 

The  pulmonary  attachment  of  the  fold  descends  from  the  lower  angle 
of  the  hilus,  usually  just  posterior  to  the  oesophageal  surface  of  the  oeso- 
phageal tuberosity. 

The  broad  pulmonary  ligament  is  formed  by  a  right  and  left  pleural 
fold,  passing  between  the  posterior  inferior  portion  of  the  mediastinal  lung 
surface,  below  the  hilus  and  the  adjacent  surface  of  the  oesophagus.  The 
arrangement  of  the  folds  is  schematically  indicated  in  Fig.  XXXI Y,  rep- 
resenting a  thoracic  transection  below  the  region  of  the  hilus. 

E.  Arrangement  of  Main  Structures  at  Hilus. 
1.  Left  Lung. 

The  t}q3ical  condition  is  seen  in  Fig.  XXYII,  12-15. 


334  REPORT   OF   THE   SOCIETY    OF   THE    LYING-IN    HOSPITAL. 

The  section  of  the  stnu-turi's  h;is  heeii  iiuule  just  before  they  enter  the 
lung. 

The  left  puhnonai'v  artery  (12)  oecn))ies  tlie  highest  position.  Tlie  sec- 
tion has  passed  through  the  vessel  at  the  point  where  the  apical  branches 
for  the  supply  of  the  suj)erior  portion  of  the  u])per  lobe  are  given  off,  the 
two  sui)erior  extensions  of  the  lumen  seen  in  the  cross  cut  indicating  these 
vessels.  The  su])erior  left  jiulnionary  vein  (l:})  lies  in  front.  Immedi- 
ately behind  this  vessel,  and  below  the  pulmonary  artery,  the  left  bron- 
chus a])|>ears  in  section  immediately  beyond  the  primary  division. 

The  left  inferior  pulmonaiy  vein  (15)  occu])ies  the  lowest  and  most 
|K)sterior  ])osition. 

Fig.  XX\'I  shows  the  same  structures  divided  a  little  nearer  to  the 
lung. 

The  main  ])ulmonary  artery  (11)  appears  above  and  behind,  the  supe- 
rior pnlmonary  vein  (1<»)  above  and  in  front,  already  divided  into  two 
main  branches. 

JJetwccn  lo  antl  11,  and  crossed  l)y  tlie  foi'king  of  the  former  line,  are 
seen  the  openings  of  the  two  a])ieal  branches  of  the  pulmonary  artery 
suj)plying  the  u]>per  lobe. 

\'2  and  Vo  are  the  two  2)rimary  bronchial  trunks,  and  the  inferior 
biimch  of  the  left  pulmonary  vein  again  occupies  the  inferior  posterior 
angle  of  the  hilus. 

2.   Iiif//it  Lnu(j. 

In  Fig,  XXX  the  right  bronchus  is  cut  after  the  division  into  the  eparte- 
rial  (17)  and  hyparterial  trunks  (20). 

The  aj)ical  branches  of  the  right  pulmonary  artery,  sui)plying  the  upper 
lobe  (18,  10),  appear  in  front  and  below  the  eparterial  bronchus.  Above 
the  latter,  between  it  and  the  azygos,  appears  the  apical  pulmonary  vein 
(not  numbered  in  the  figure). 

The  main  trunk  of  the  pulmonary  artery  (22)  is  in  this  section  still 
quite  in  front  of  the  hyparterial  bronchus. 

On  the  same  level,  constituting  the  most  anterior  structure,  aj)pears  the 
section  of  the  upper  right  pulmonary  vein  (21),  while  the  inferioi-  ])ulmo- 
nary  vein  (23)  is  seen  below  and  l>ehind  the  hyparterial  bronchus. 

In  Fig.  XXVIII  the  same  ai'rangement  of  the  structures  is  found,  the 
main  pulmonary  artciy  occn])ying  the  position  between  the  hypai'terial 
bronchus  and  right  su])eriof  piibuonary  vein. 

In  Fig.  XXIX  the  bronchus  is  cut  just  at  th(3  j)oint  of  division  into 
(•partr'rial  and  hyparterial  truidcs  (IIV  The  main  ]>uli nonary  artery  lies 
in  front,  a|)plied  to  the  aiitci-ioi-  and  infci'ior  Ijoi-dcr  of  the  l)ronchial  cross 
cut.  The  aj)ical  )>u]ni(jnary  artei-ies  (H,  l())ai-e  ali'eady  given  off,  and  lie 
in  front  of  the  upj)er  (epai-tfvial  i  ]»ortion  of  the  bronchial  section. 

The  upper  and  lower  pi ih nonary  veins  occupy  the  usual  position  at 
the  anterior  and  inferior  jiortion  of  the  hilus  region. 

Tlie  .sections  demon.strate  well  the  early  derivation  and  separate  ajiterior 
course  of  the  apical  ])ulmonary  arterial  brandies  and  tin;  position  of  the 
main  arterial  trunk  jirior  to  the  intersection  with  the  bi'onclii.il  fot-k. 


ANATOMY    OF   THE   THORAX    IN   THE    FCETUS   AT   TERM,    ETC.  335 


II.  Topography  of  Mediastinum  and  Mediastinal  Surface  of  Lung. 

As  previously  stated,  the  formaline-hardened  lung  admits  of  removal 
from  the  thorax  without  impairing  the  natural  form  of  the  organ.  The 
mediastinal  surface  of  the  lung  carries  with  it  impressions  which  corres- 
pond to  the  relations  with  the  mediastinal  contents,  and  which  afford  a 
means  of  determining  accurately  the  extent  of  such  relations.  In  the  fol- 
lowing, certain  portions  of  the  mediastinal  lung  surface  will  be  described 
as  being  ''  in  contact "  with  certain  structures  contained  in  the  mediastinal 
space.  It  will,  of  course,  be  understood  that  the  mediastinal  parietal  pleura 
intervenes.  In  the  same  way,  to  avoid  circumlocution,  such  terms  as 
"  oesophageal  "  or  "  tracheal  "  "  surface  "  or  "  area  "  will  be  employed,  in 
describing  certain  regions  of  the  mediastinal  lung  surface.  Here,  again,  the 
interposition  of  the  parietal  pleura  is  assumed  without  further  specifica- 
tion. 

1.   TojKxjraphy  of  Mediastinal  Contents.     Riglit  Side. 

In  Fig.  XXYIII  (foetus  at  term,  E)  the  right  lateral  view  of  the  medi- 
astinal contents  is  given,  after  removal  of  the  lung  by  division  of  the  struc- 
tures entering  and  leaving  the  viscus  at  the  hilus,  the  parietal  pleura 
remaining  in  place.  In  Fig.  XXIX  (foetus  at  term,  D)  the  same  structures 
are  shown,  with  the  upper  portion  of  the  mediastinal  pleura  reflected.  In 
Fig.  XXX  (infant,  immediately  after  birth,  F)  the  mediastinal  contents, 
hardened  in  situ.,  are  removed  from  the  thorax  and  viewed  from  the  right 
side  and  behind. 

These  structures,  thus  built  together  and  invested  by  the  mediastinal 
pleura,  form  the  bed  upon  which  the  mediastinal  surface  of  the  right  lung- 
rests.  The  elevations  and  depressions  of  this  portion  of  the  parietal  pleura, 
caused  by  the  more  marked  projection  of  certain  of  these  structures  into 
the  right  pleural  sac,  produce  a  corresponding  modelling  of  the  internal 
surface  of  the  lung.  We  will  see  that  the  plastic  lung  substance  adapts 
itself  to  the  opposed  mediastinal  pleural  surface,  and  takes,  so  to  speak,  a 
negative  cast  of  the  inequalities  of  this  surface.  The  appearance,  therefore, 
of  the  mediastinal  surface  of  the  lung  will  best  be  appreciated  by  first 
considering  the  arrangement  of  the  mediastinal  contents  which  ])roduce  this 
appearance. 

In  Fig.  XXYIII  the  anterior  portion  of  the  right  sternocostal  pleura 
is  seen  to  be  reflected  to  form  the  mediastinal  leaf,  along  a  curved  line, 
convex  forward,  ^vhich  descends  from  behind  the  right  sternoclavicular 
articulation,  over  the  anterior  surface  of  the  thymus  gland  and  the  peri- 
cardium. These  two  structures  form  together  the  contents  of  the  anterior 
and  larger  division  of  the  mediastinal  space. 

The  lateral  surface  of  the  thymus  (Fig.  XXYIII,  9,  Fig.  XXIX,  8) 
constitutes  approximately  the  upper  third,  the  pericardium  the  lower  two- 
thirds  of  the  area  in  vertical  measurement.  In  the  sagittal  direction  the 
area  increases  steadily  from  the  sharp  point  with  which  the  lateral  surface 
of  the  th}Tnus  begins  to  appear  in  the  right  mediastinal  wall  above,  to 


330  REPORT   OF   TUE   SOCIETY    OF   THE    LYING-IX    HOSl'TTAL. 

the  broad  antero-postci-ior  extent  of  the  rig-ht  margin  of  the  pericardium 
at  its  attachment  to  the  ilia))hrauin  l)eh)\v.  Tlie  hiteral  surface  of  the 
thvmns.  invested  thus  by  the  anterior  and  upjier  jiart  of  tlie  mediastinal 
l>leurti,  is  phme.  or  even  slightly  concave,  lietween  it  and  the  }>rominent 
right  lateral  surfjice  of  the  pericardium  a  furrow  running  obliquely  down- 
ward and  forward  receives  the  ridge  which,  on  the  mediastinal  surface  of 
the  right  lung,  se})arates  the  thymic  from  the  concave  pericardial  area 
(Fig.  XXX,  between  H  and  3V 

Behind  the  thymic  area  the  ]n-ominent  lateral  surface  of  the  right 
innominate   vein   and    superior   vena   cava   is   seen    (Figs.   XXA'III,   10, 

XXIX,  continuation  downwards  of  3,  XXX,  15).  In  the  foetus  the  por- 
tion of  the  right  innominate  vein  in  contact  with  the  mediastinal  pleura  is 
com]>aratively  short,  inclined  obliquely  across  the  up]:)er  apical  ])ortion, 
whereas  the  superior  cava  appears  relatively  long,  directed  more  vertically 
ilownwards.  dorsal  to  the  thymus  and  upper  right  portion  of  the  pericar- 
dium. 

The  right  phrenic  nerve  descends  between  the  superior  cava  and  the 
thpnus,  and  lower  down  crosses  the  pericardium  in  front  of  the  structures 
connected  with  the  pulmonary  hilus,  to  continue  along  the  anterior  and 
lateral  cii'cumference  of  the  inferior  vena  cava  to  the  diaphragm  (Figs. 
XXVIII,  8,  XXX,  16). 

Tlie  posterior  portion  of  the  mediastinal  space  is  occu])ied  in  its  middle 
thiril  l)y  the  structures  connected  with  the  lung  at  the  hilus,  and  already 
considered  in  detail  in  reference  to  their  mutual  relations. 

Immediately  al)ove  the  upper  margin  of  the  hilus  region  the  azygos 
vein  arches  from  behind  forward  to  join  the  superior  cava  (Figs.  XXVIII, 
2,  XXIX,  1,  XXX,  4). 

Ik'tween  the  innominate  and  superior  caval  veins  in  front,  the  verte- 
l)ral  column  behind,  the  apex  of  the  ])leural  sac  above,  and  the  az^^gos  arch 
below,  the  right  mediastinal  pleura  covers  a  field  (Fig.  XXVIII,  1)  which, 
after  reflection  of  the  membrane  (Figs.  XXIX  and  XXX),  is  seen  to  con- 
tain the  foUijwing  structures:  The  right  lateral  wall  of  the  trachea  occupies 
tlie  central  portion  of  this  area  (Figs.  XXIX,  <i,  XXX,  continuation  of  8). 
The  tul>e  is  separated  from  the  large  venous  trunks  in  front  by  a  quantity 
of  fatty  connective  tissue  and  small  lymphatic  glands  (Figs.  XXIX,  7, 

XXX,  18),  and  is  crossed  obli(piely  in  the  direction  from  above  and  in  front 
downward  and  backward  by  the  right  vagus  (Figs.  XXIX,  5,  XXX,  4). 

Behind  the  trachea,  l)Otween  it  and  the  vertebral  column,  the  right 
lateral  jMjrtion  of  the  oeso[)hagus  appears  (Figs.  XXIX,  4,  XXX,  contin- 
uation of   1  ). 

At  the  level  of  the  up])er  border  of  the  hilus  the  fcsophagus  encounters 
the  arch  of  tlie  azygos  vein.  The  vein  is  rendered  very  jn'ominent  at  tliis 
jKiint  by  tiie  underlying  oesophagus.  ;iii(l  piojeets  strongly  into  the  right 
l)leural  siic.  Dorsal  to  the  region  of  the  hihis  the  vein  gi-Khially  beeomes 
less  ])rominent,  and  recedes  toward  the  median  line.  The  i-igiit  lateral  sur- 
face of  the  ce.sopha^s  again  appears  below  the  arch,  between  the  vertical 
azygos  vein  Ijeliind  ;m(l  the  prricjifdium  jmd  structures  at  tlic  hilus  in  IVniit. 


ANATOMY    OF   THE   THORAX    IN    THE    FCETUS   AT   TERM,    ETC.  337 

The  oesophageal  surface  in  contact  with  the  right  mediastinal  pleura  grad- 
ually increases  as  the  vein  recedes.  At  the  beginning  of  the  lower  third  of 
the  space  the  oesophagus  has  entirely  replaced  the  vein  in  relation  to  the 
pleural  leaf.  In-  this  situation  the  inferior  oesophageal  branches  of  the 
vagus  are  seen  shining  through  the  investing  pleura  (Fig.  XXVIII,  4). 

Below  the  hilus  and  in  front  of  the  oesophagus  is  the  prominent  pos- 
terior and  lateral  wall  of  the  intrathoracic  segment  of  the  inferior  cava 
(Figs.  XXVIII,  19,  XXX,  24). 

Behind  the  oesophagus  and  azygos,  covered  by  the  costovertebral 
pleura,  are  seen  the  intercostal  vessels,  and  more  laterally  the  longitudinal 
strand  of  the  sympathetic  nerve. 

2.  Mediastinal  Surface  of  Right  Lung  (Figs.  XX,  XXII,  XXIIa, 
XXIII). 

Boundaries : 

In  front:  anterior  sharp  margin. 

Below:  mediastino-phrenic  margin. 

Behind:  internal  margin. 

This  surface  of  the  lung  is  modelled  on  the  mediastinal  pleura  covering 
the  contents  of  the  space,  as  above  detailed,  and  accordingh^  presents  a 
natural  division  into  three  fields  of  unequal  extent  and  conformation. 

(1)  Region  in  Front  of  Hilus. 

a.  Thymic  area. — The  upper  third  is  formed  by  a  smooth,  slightly  con- 
vex surface  in  apposition  Avith  the  parietal  pleura  covering  the  lateral  sur- 
face of  the  thymus  gland  {thymic  area)  (Figs.  XX,  XXII,  XXIII,  3), 
and  moulded  over  the  form  of  this  organ.  The  thymic  area  occupies  the 
upper  half  of  the  medial  surface  of  the  upper  lobe. 

h.  Pericardial  area. — The  loAver  two-thirds  of  the  anterior  region 
include  nearly  equal  portions  of  the  upper  and  middle  lobes,  forming  a 
concave  surface  {jjericardicd  area)  moulded  over  the  prominence  of  the  peri- 
cardium (Figs.  XX,  XXII,  XXIII,  2).  This  area  extends  backward  to 
the  anterior  margin  of  the  hilus,  and  presents  immediately  in  front  of  the 
latter  a  narrow,  linear,  nearly  vertical  furrow,  resulting  from  its  relation  to 
the  right  phrenic  nerve. 

The  pericardial  area  is  separated  from  the  thymic  surface  by  a  moder- 
ately prominent  blunt  ridge,  which  corresponds  to  the  furrow  between  the 
lateral  surface  of  the  thymus  and  the  pericardium. 

(2)  Region  of  Hilus. 

a.  Hilus. — Irregularly  oval,  with  longest  diameter  in  the  long  axis  of 
the  lung.  The  posterior  border  is  nearly  vertical;  the  anterior,  convex. 
The  upper  extremity  is  blunt,  quadrangular;  the  lower  extremity  pointed. 

The  arrangement  of  the  chief  structures  entering  and  leaving  the  lung 
at  the  hilus  has  been  described  above  in  detail. 

I).  Surface  ahove  hilus  presents  in  front  a  sharply  defined  vertical 
groove  for  the  reception  of  the  lateral  surface  of  the  right  innominate  and 
superior  caval  veins.  (Figs.  XX,  XXII,  XXIII,  4).  The  posterior  bor- 
der of  this  groove,  immediately  above  the  hilus,  is  interrupted  by  the  junc- 
tion of  the  caval  depression  with  the  deep  groove  lodging  the  terminal 


338  REPORT   OF   TF^E   SOCIETY    OF   THE    LYIN'G-IN    HOSPITAL. 

]>art  of  the  azvgos  vein  vFigs-  XX,  XXII,  XXIII,  0).  The  latter  curves 
from  beliiiul  forward,  following  closely  the  superior  margin  of  the  hilus. 

Anteriorly  the  caval  iinjn-ession  is  prolonged  down  to  nearl}'-  the  middle 
of  the  anterior  nuirgin  of  the  hihis,  forming  by  its  anterior  margin  the 
jx)sterior  boundary  of  the  thyniie  area. 

Behind  the  eaval  impression  is  a  smooth  quadrangular  field  (Figs.  XX, 

XXII,  XXIII,  '*)  in  contact  with  the  pariet;il  ])]eura,  which  here  covers 
smoothly  the  riglit  lateral  surface  of  the  ti-acliea,  the  peritracheal  lymphatic 
and  fattv  connective  tissue,  and  the  right  vagus,  which  crosses  this  segment 
of  the  trachea  obliquely  from  above  aiul  in  front  downwards  and  back- 
waitls. 

c.  Surface  hehtc  /<//</.s\ — A  rectangular  i)ortion  of  the  inferior  lobe, 
deeplv  concave,  surrounds  the  lateral  as])ect  of  the  inferior  cava  (Figs. 
XX,  XXII,  XXIII,  1). 

This  caval  surface  is  l)ounded  above  by  the  inferior  margin  of  the  hilus, 
in  front  l)y  the  prolongation  of  the  main  interlobar  incisure  from  the 
])hrenic  surface  upward  and  backward  upon  the  mediastinal  surface  to  the 
lower  i)art  of  the  anterior  border  of  the  hilus.  Behind,  the  caval  area  is 
Hmited  by  a  prominent  vertical  ridge  of  lung  tissue,  which  fits  into  the 
deep  angular  interval  between  the  oesophagus  and  the  vena  cava,  and  which 
carries  along  its  dorsal  nuirgin  the  attachment  of  the  broad  pulmonary 
ligament. 

(8)  Region  hehind  JIUx.s. 

This  region  is  occupied  by  a  narrow,  vertical  field,  enlarging  somewhat 
below,  which  se])arates  the  mediastinal  from  the  costovertebral  surface, 
and  wliich  is  in  relation  ^\•ith  the  oeso])hagus  and  the  proximal  portion  of 
the  azygos  vein,  Ijoth  structures  A\'hich  produce  more  or  less  well  marked 
grooves  on  this  ])ortion  of  the  lung  surface. 

Above  the  level  of  the  upper  border  of  the  hilus,  from  the  region  of 
the  apex  down,  a  narrow,  vertical  area,  situated  dorsal  to  the  smooth 
ti-aehcal  surface,  is  in  contact  with  the  mediastinal  pleura  covering  the 
uj)i>er  thoracic  portion  of  the  oesophagus.  This  area  is  separated  from  the 
costovertebral  surface  by  a  prominent,  well-defined,  sharp  margin,  pass- 
ing into  tlie  apical  region  above,  and  continuous  l)elow  with  the  ])osterior 
bordi-r   of    the   azygos  groove.       This    margin   (Figs.    XX,    XXII,    and 

XXIII,  behind  5)  fits  into  the  angle  between  the  upper  portion  of  the 
CL'Sophagus  and  tlie  vertebral  column. 

At  the  level  of  tlie  upper  horde]-  of  the  hilus  the  sharply  defined  curved 
groove  caused  by  the  arch  of  the  azygos  vein  tui'us  downward,  dorsal  to 
the  hilus  (Figs.  XX,  XXII,  XXTII,  0).  Ju  tlic  beginning  of  its  vertical 
coursf*  the  groove  is  well  marked.  In  some  lungs  a  faint  impression  crosses 
the  uj)per  ])art  of  the  costoverti^bi'al  sui-face  obli(|uely,  ti)  join  the  azygos 
groove.  Tliis  sr-cond  inipi-cssion  is  cnnscd  1)\-  the  siipci'ior  intercostal 
vein. 

Below,  the  azygos  ^ri-oovr  gr;i(hi;illy  becomes  less  dislincl,  nnd  ]nerg(^s 
into  a  somowliat  broader  sui-fiicc.  which  lies  b('t\v<M'n  the  postci-ior  mai'gin 
of  the  hilus  and    the  costoverteljral  sui-facc      Reference  to  the  structures 


ANATOMY   OF   THE   THORAX    IN   THE    FCETUS   AT  TERM,    ETC.  339 

left  hi  situ  in  the  posterior  part  of  the  mediastinum  after  removal  of 
the  right  lung  explains  this  appearance  (Figs.  XXVIII,  XXX).  The 
azygos  vein,  ascending  in  the  mediastinum,  occupies  in  main  a  nearly 
medial  position,  only  beginning  to  deviate  markedly  to  the  right  on  reach- 
ing the  level  of  the  sixth  thoracic  vertebra.  Above  this  point  the  vein 
comes  into  close  contact  with  the  right  mediastinal  pleura  and  impresses 
the  mediastinal  surface  of  the  lung  behind  the  hilus,  as  indicated.  Below 
this  point  the  vein  gradually  recedes  from  the  mediastinal  pleura,  and,  on 
reflecting  the  membrane,  the  riglit  lateral  margin  of  the  oesophagus  begins 
to  appear  between  the  posterior  margin  of  the  hilus  and  vein.  This 
oesophageal  area  begins  above  as  a  narroAV  pointed  surface  which  expands 
in  descending,  until  in  its  lower  portion  it  equals  the  inferior  vena  cava  in 
sagittal  measure.  With  the  parts  undisturbed  and  in  their  natural  condi- 
tion, the  gradual  recession  of  the  azygos  vein  from  contact  with  the  right 
mediastinal  pleura,  and  its  replacement  in  relation  to  the  meml^rane  by 
the  right  border  of  the  oesojDhagus,  is  affected  without  producing  any 
abrupt  line  of  demarcation.  Consequently,  in  the  hardened  lung  removed 
from  the  thorax,  the  azygos  groove,  sharp  and  well  defined  above,  gradu- 
ally fades  out  below  the  middle  of  the  hilus,  and  is  replaced  by  the  broader, 
smooth  surface  in  contact  with  the  mediastinal  pleura  investing  the  oesoph- 
agus (Figs.  XX,  XXII,  XXIII,  '7). 

The  entire  region  of  the  mediastinal  lung  surface  dorsal  to  the  hilus  is, 
therefore,  composed  of  an  upper  narrower  and  lower  wider  oesophageal 
area,  separated  from  each  other  by  the  surface  in  contact  with  the  azygos 
vein.  The  latter  structure  is  rendered  prominent  in  the  upper  mediastinal 
region  by  its  course  upward,  forward,  and  to  the  right,  and  by  the  under- 
lying oesophagus.  Below  the  middle  of  the  hilus,  on  the  other  hand, 
the  vein  gradually  recedes  from  the  mediastinal  pleura  and  lies  nearer  the 
median  line,  being  enabled  to  assume  this  position  by  passing  behind  the 
oesophagus,  the  latter  tube  gradually  inclining  forward,  and  ceasing  its 
close  apposition  to  the  anterior  surface  of  the  vertebral  column. 

The  relative  extent  of  these  areas  of  relation  of  the  mediastinal  lung 
surface  with  the  contents  of  the  mediastinum  is  shown  schematically  in 
Fig.  XXIIa. 

3.   Topography  of  Mediastinal  Contents.     Left  Side. 

Fig.  XXYI  shows  the  mediastinal  contents  in  situ  covered  by  the 
pleura  in  a  foetus  at  term  (i>),  and  Fig.  XXYII  shows  the  same  structures 
removed  from  the  thorax,  with  the  pleura  partially  reflected,  in  the  infant 
immediately  after  birth  {F). 

In  front,  as  on  the  right  side,  the  lateral  surface  of  the  thvmus  gland 
(XXVI,  5,  XXVII,  4)  appears  above,  the  prominent  pericardium  (XXVI, 
7)  below,  the  latter  crossed  obliquely  by  the  left  phrenic  nerve  (XXVI, 
6,  XXVII,  5).  At  the  upper  and  posterior  margin  of  the  left  pulmonary 
root,  the  arch  of  the  aorta  produces  a  marked  elevation  of  the  mediastinal 
pleura,  which  is  continued  along  the  entire  posterior  border  of  the  medias- 
tinum by  the  thoracic  aorta,  the  elevation  becoming  gradually  less  marked 
as  the  vessel  approaches  the  diaphragm  (XXVI,  15,  XXVII,  16). 


340  REFORT   OF   THE   SOCIETV    OF   THE    LYING-IN    HOSPITAL. 

Above  the  level  of  the  upper  hihis  margin,  between  the  vertebral 
column  behiuil  and  the  thymus  gland  in  front,  the  mediastinal  pleura 
covei"s  the  follow ini::  structures: 

1.  Immetliately  in  front  of  the  vertebral  column  the  left  margin  of  the 
oesophagus  (XXVI,  7). 

'2.  The  intrathoracic  seiiineut  of  the  left  subclavian  artery,  forming  a 
prominent  rounileil  ridge  in  the  mediastinal  wall  (XXVI,  S,  XXA^II,  0). 

3.  In  front  of  the  subclavian  elevation  the  mediastinal  pleura  covers 
smoothly  a  field  (presubclavian)  (Fig.  XXYI,  4)  in  which  are  placed  the 
left  common  carotid  arteiy  (XXVII,  8),  the  left  vagus  (XXVII,  9),  and  a 
quantity  of  fatty  and  lymphatic  tissue  (XXVII,  3)  which  lies  behind  the 
thvmus  and  left  innominate  vein. 

The  latter  structure  a])pears  in  the  upper  and  anterior  angle  of  this 
surface  behind  the  thymus  (XXVII,  continuation  downward  of  1),  and 
frecjuently  receives  the  left  su])erior  intercostal  vein  (Fig.  XXVI,  9, 
XXVII,  11\  which  passes  upward  and  forward  from  below  and  behind, 
crossing  the  aortic  arch  and  pneumogastric  nerve,  the  nerve  being  placed 
])et\veen  the  arch  and  the  vein. 

The  internal  mammary  artery  (XXVII,  2)  crosses  the  upper  angle  of 
the  lateral  thymus  surface  and  the  innominate  vein  (XXVII,  2),  and  the 
upper  part  of  the  intrathoracic  segment  of  the  left  phrenic  nerve  descends 
behind  the  innominate  vein,  crossing  usually  over  the  point  of  entrance 
into  the  latter  of  the  superior  intercostal  vein. 

Below  the  hilus  the  pericardium  projects  decidedly  into  the  left  pleural 
compartment.  This  is  especially  marked  along  the  posterior  inferior  seg- 
ment, where  the  pericardium  covers  the  prominent  posterior  part  of  the  left 
tliick  ventricular  margin  and  the  adjoining  posterior  and  inferior  part  of 
the  left  auricle. 

Jietween  the  elevation  of  the  ])osterior  })art  of  the  left  mediastinal  leaf 
])roduced  ]>y  the  thoracic  aorta  behind  (XXI,  15,  XXVII,  16),  the 
dia])hragm  below,  the  ])ortion  of  the  pericardium  referred  to  in  front  and 
alxn'e,  Avith  the  entrance  of  the  left  infei'ior  jiulmonary  vein  as  its  u])per 
limit  (XXVII,  15),  the  left  pleural  cavity  exhibits  a  deep  triangular  recess, 
bounded  internally  by  the  pleura  covering  the  left  side  of  the  lower  tho- 
racic segment  of  the  oesophagus.  One-half  of  the  circumference  of  the 
a-sophagus  appears  thus  in  the  inner  wall  of  this  recess,  after  the  tube  has 
])iusse<l  the  ])osterior  surface  of  the  left  auricle,  in  the  interval  between 
afirta  beliind,  pericardium  in  front,  and  diapliragm  below  (XXVI,  10, 
XXVII,  IS). 

4.  Mtduuiinal  tiurface  of  Lefl  Luikj. 

This  surface  corres])onds  to  the  structui-es  above  described,  and  is  mod- 
filed  accordingly  (Figs.  XV,  XVII,  XVIIa).  The  lower  and  longer  i)art 
is  occupied  by  the  deep  and  well-marked  impression  for  the  left  side  of 
the  |K!ricanliuni  CXV,  XVII,  7).  The  greater  ])oi'tion  of  this  ])ericardial 
surface  is  fornic<l  l)y  the  medial  surface  of  tin;  upp<M'  lobe.  A  ])oi"tif)n  <^f 
the  inferior  iribe  contributes  a  smaller  ])ericar(lial  surface  to  be  presently 
considered  in  detail. 


ANATOMY   OF   THE    THORAX    IN   THE    FCETUS   AT   TER^[,    ETC.  341 

Immediately  above  the  pericardial,  area  the  medial  surface  of  the  left 
lung  rests  on  the  mediastinal  i)leura  covering  the  left  lateral  surface  of 
the  th3''mus  gland.  This  thymic  surface  (XV,  XVII,  6)  in  the  hardened 
lung  is  plane  or  slightly  convex,  and  is  separated  from  the  pericardial 
depression  immediately  below  by  a  raised  curved  margin,  with  the  concav- 
ity directed  downward  and  backward,  which  corresponds  to  the  curved 
groove  separating  the  thymus  in  situ  from  the  pericardium.  In  well-hard- 
ened lungs  a  faint  linear  impression  descending  obliquely  along  the  pos- 
terior margin  of  the  thymic  area  is  due  to  the  left  phrenic  nerve. 

Above  the  liilus  the  medial  surface  of  the  lung  is  grooved  by  the  arch 
of  the  aorta  (XV,  XVII,  3).  This  groove  begins  as  a  faint  depression 
which  rapidly  deepens  until  it  obtains  its  greatest  development  just  above 
and  behind  the  superior  posterior  angle  of  the  hilus.  At  this  point  a  nar- 
rower, deep,  nearly  vertical  groove  passes  upward  to  the  upper  margin  of 
the  lung,  produced  by  the  intrathoracic  segment  of  the  left  subclavian 
artery. 

Between  the  subclavian  groove  behind,  the  upper  border  of  the  aortic 
furrow  below,  the  upper  lung  margin  above,  and  the  thymic  surface  in 
front,  the  medial  aspect  of  the  left  lung  presents  a  smooth,  nearly  plane 
field  (presubclavian  area,  XA-^,  XVII,  5),  which  rests  on  the  mediastinal 
pleura  covering  the  proximal  portion  of  the  left  common  carotid  artery 
and  the  left  vagus,  embedded  in  a  quantity  of  fatty  and  granular  connec- 
tive tissue. 

If  the  superior  intercostal  vein  is  large,  a  shallow  linear  impression  may 
be  produced  by  it,  intersecting  the  aortic  groove  obliquely. 

Behind  the  hilus  the  aortic  groove  continues  to  be  marked,  descending 
nearly  vertically.  It  can  be  followed  to  the  lower  border  of  the  lung, 
growing  gradually  somewhat  shallower. 

Below  the  hilus,  and  in  front  of  the  lower  portion  of  the  aortic  groove, 
the  medial  lung  surface  presents  a  well-marked  triangular  process,  which 
can  be  called,  with  regard  to  its  relations,  the  pericardio-oesophageal  tuber- 
osity. It  occupies  the  triangular  mediastinal  recess  above  described, 
between  aorta  behind  and  pericardium  in  front,  and  containing  at  the  bot- 
tom the  left  wall  of  the  oesophagus. 

The  pericardio-oesophageal  tuberosity  is  a  product  of  the  medial  sur- 
face of  the  inferior  lobe.  It  starts  just  in  front  of  the  lowest  point  of  the 
hilus  in  form  of  a  ridge  (XV,  XVII,  2),  which  graduaU}^  becomes  more 
and  more  elevated  in  proceeding  downward,  forward,  and  inward.  The 
tuberosity  thus  produced  presents  three  surfaces,  two  mediastinal  and  one 
phrenic.  The  phrenic  surface  constitutes  the  most  anterior  and  medial 
portion  of  the  area  which  the  inferior  lobe  contributes  to  the  formation  of 
the  basal  surface  of  the  left  lung  (Fig.  XIII,  4). 

The  mediastinal  surfaces  are  an  anterior  and  a  posterior.  The  anterior 
surface  (XV,  XVII,  8)  is  concave,  and  contributes  to  the  formation  of  the 
pericardiac  depression. 

In  some  instances  the  return  of  the  main  interlobar  incisure  to  the 
anterior  and  inferior  border  of  the  hilus  on  the  medial  surface  of  the  lung 


342  REPORT   OF   THE   SOCIETY    OF   THE    LYTXG-IX   HOSPITAL. 

limits  this  pericardial  surface  of  the  tuberosity  above  and  in  front  (Fig". 

x\n). 

In  other  cases  the  ]>ericardial  surface  contrilmted  by  the  inferior  \o\)e  is 
mueh  hirirer  and  exceeds  tlie  limits  of  tlie  tul)erosity.  The  interlobar 
incisure  then  passes  up  \v  a  I'd  and  backward  more  vertically  from  the  ante- 
rior j)art  of  the  mediastino-phi'enic  border,  and  reaches  the  hilus  nearly  at 
the  miiUUe  of  its  anterior  margin  (Fig.  XV).  In  such  a  case  the  pericar- 
dial surface  of  tlie  tuberosity  is  continuous  with  the  general  pericardial 
surface  of  the  inferior  lobe,  constituting  the  posterior  inferior  segment 
of  the  Siime. 

The  posterior,  or  oesophageal,  surface  of  the  tuberosity  (XY,  XVII,  9) 
looks  backward  and  inward,  and  rests  ujjon  the  pleura  covering  the  por- 
tion of  the  tt'sophagus  which  appears  between  aorta,  pericardium,  and 
diaphragm.  The  surface  is  triangular,  with  a  broad  posterior  vertical  base. 
The  lateral  borders  are  formed  below  by  the  postero-internal  part  of  the 
shar])  mediastino-phrenic  margin  of  the  lung,  and  above  and  in  front  by 
the  ridge  above  described  as  proceeding  from  the  lower  angle  of  the  hilus. 
This  ridge  separates  the  pericardial  from  the  oesophageal  surface,  and  cor- 
res])onds  to  the  dejiression  betAveen  pericardium  and  oesophagus. 

Tlie  pericartlio-oesophageal  tuberosity  of  the  left  lung  evidently  corres- 
ponds to  the  elevated  ridge  of  lung  tissue  wdiich,  on  the  right  side,  fits  into 
the  narrow  interval  between  oesophagus  behind  and  the  inferior  vena  cava 
in  front. 

'  The  attachment  of  the  broad  ligament  is  dorsal  to  the  oesophageal  sur- 
face of  the  tuberosity,  the  layers  descending  almost  verticall}^  from  the 
lower  angle  of  the  hilus.  At  the  attachment  of  the  ligament  to  the  lung, 
or  just  anterior  to  this  line,  a  sharp  vertical  ridge  is  frequently  observed 
which  fits  into  the  depression  between  aOrta  and  oesophagus. 

In  well-hardened  lungs  a  vertical  linear  impression,  descending  over  the 
costovertebral  surface,  indicates  the  relation  to  the  sympathetic  strand 
and  the  line  of  the  costal  capitula. 

The  relation  of  the  thoracic  duct  to  the  mediastinal  pleura  has  not  been 
determined  in  the  above  preparations,  as  the  demonstration  of  the  same 
would  produce  too  much  disturbance  in  the  arrangement  of  the  remaining 
structures. 

AVith  this  exception  the  al>ove  account  is  believed  to  present  the  main 
relations  of  the  lungs  and  mediastinal  contents  correctly. 


III.   TirvMus  Gland. 

rFigs.    will.    WIN',    XXVI,   XXVII,   XXVIII,  XXXI,  XXXII, 

XXXIII.) 

TIh!  gland,  situati-d  ]>;irtly  witliin  tlic  thorax,  ])artly  in  the  anterior 
cervical  region,  is  placed  in  front  of  the  pericardium  and  the  beginning 
and  termination  of  the  large  vessels,  accurately  adapting  itself  to  the  struc- 
tures with  which  it  comes  into  contact. 


ANATOMY    OF   THE   THORAX    IX   THE    FCETUS   AT   TERM,    ETC.  343 

The  thoracic  portion  presents  in  the  gland  hardened  in  situ  five  distinct 
surfaces,  as  follows: 

Anterior,  mediastinal. 

Two  lateral,  pleural. 

Posterior,  vascular. 

Inferior,  pericardiac. 

The  arrangement  of  the  surfaces  is  well  seen  in  the  view  of  the  gland 
in  situ  from  the  side,  as  in  Fig.  XXYIII.  The  anterior  or  mediastinal  sur- 
face is  directed  upward  and  forward  in  the  upper,  more  directly  forward 
in  the  lower,  part.  Viewed  from  in  front  (Figs.  XYIII,  1,  XXXI,  10) 
this  surface  is  seen  to  be  triangular,  with  the  apex  directed  downward. 
Above,  the  base  is  continuous  with  the  anterior  surface  of  the  cervical  por- 
tion (XYIII,  5,  XXXI,  7).  The  sides  are  bounded  by  the  sternocostal- 
mediastinal  reflections  of  the  right  and  left  parietal  pleura  (XXXI,  3,  11), 
which  pass  from  the  sternum  directly  backward,  to  invest  the  lateral  sur- 
faces of  the  gland. 

The  inferior  surface  looks  backward  and  downward,  and  rests  on  the 
upjjer  and  anterior  portion  of  the  ]3ericardium. 

The  lateral  surfaces  (XXYII,  4,  XXYIII,  9),  invested  by  the  ante- 
rior portion  of  the  mediastinal  pleura,  look  directly  outward,  and  are  in 
relation  with  the  thymic  area  on  the  medial  surface  of  each  lung. 

The  phrenic  nerve  descends  on  each  side,  near  the  posterior  border  of 
the  lateral  surface  (XXYIII,  8,  XXYII,  5).  On  the  right  side  this  pos- 
terior border  rests  on  the  right  innominate  vein  and  the  superior  cava 
(XXYIII,  10).  On  the  left  side  the  posterior  limit  of  the  lateral  surface 
is  formed  above,  for  a  short  distance,  by  the  left  innominate  vein ;  below,  by 
some  fatty  and  lymphatic  gland  tissue  lying  between  the  vein,  the  trachea, 
and  the  left  common  carotid  artery  (XXYII,  3).  The  upper  angle  of  this 
surface  is  crossed  from  behind  forward  by  the  left  internal  mammar}'" 
artery  (XXYII,  2). 

The  greatest  interest  attaches  to  the  posterior  surface  and  to  the  rela- 
tions of  the  gland  to  the  large  venous  trunks  in  the  upper  and  anterior  por- 
tion of  the  mediastinum. 

In  the  typical  arrangement  the  left  innominate  vein  is  situated  entirely 
behind  the  gland.  Fig.  XXXI  shows  the  aberrant  course  of  the  vein  in 
front  of  the  gland.  This  arrangement  was  first  observed  by  Astley  Cooper 
in  1832.*  TVenzel  Gruberf  in  1876  reported  two  additional  cases.  The 
same  author  X  observed  seven  cases  in  which  the  vein  passed  through  the 
substance  of  the  gland. 

The  prethymic  position  of  the  left  innominate  vein  is,  therefore,  an 
extremely  exceptional  one.  In  the  case  observed  by  us  (Fig.  XXXI,  9) 
the  vein  traversed  the  upper  portion  of  the  mediastinum  immediately 
behind  the  manubrium,  imbedded  in  a  deep  groove  on  the  anterior  surface 
of  the  thymus,  separating  the  cervical  (7)  from  the  thoracic  portion  of  the 

*  The  Anatomy  of  the  Thymus  Gland.     London,  1832. 

t  Yh'chow's  Archiv,  Bd.  66,  1876,  p.  462:   "  Anatomische  Notizen,  No.  lii." 

X  Beobacht.  a.  d.  Menschl.  u.  Vergl.  Anat. ,  I.  Heft,  p.  41.     Berlin,  1879. 


344  REPORT   OF   THE   SOCIETY    OF   THE    LVING-IX    HOSPITAL. 

gland  (^lu).  Fig.  XW'JI  presents  the  right  hiteral  view  of  the  same 
foetus,  showing  the  relation  of  the  vein  (7)  to  the  two  portions  of  the 
glanil. 

Figs.  X\'1I1,  I,  0,  XX \' I,  I,  :>,  XXIX,  S,  show  the  anterior  and  the 
left  and  right  lateral  views  of  the  thymus  in  a  foetus  at  term  {D\  and  Fig. 
XXXII  shows  the  mediastinal  contents  of  the  same  individual  seen  from 
above,  with  the  thymus  ])artly  detached  and  turned  downward  and  forward. 
The  jx>sterior  surface  of  the  gland  is  seen  to  rest  on  the  ])ericardium  (13) 
covering  the  right  auricular  ai)pendix  (14),  the  ascending  aorta  (11)  and 
the  pulmonary  artery  (12j.  On  the  right  side  the  anterior  surface  of  the 
sujKM'ior  cava  is  in  contact  with  the  gland. 

The  upper  and  anterior  jiortion  of  the  gland  is  ])rolonged  into  the  neck 
in  form  of  an  assymmetrical  su])erior  cornu  (XYIII,  5,  XXYI,  1)  which 
lies  in  front  of  the  left  innominate  vein  (suj)erior  prevenous  cornu).  On 
turning  this  portion  of  the  gland  downward  and  forward  (XXXII)  a 
second  u})per  process  (superior  retrovenous  cornu,  XXXII,  10)  is  seen  to 
pass  u])  ht'hiiul  the  vein,  lying  between  it  and  the  large  arteries  at  the  root 
of  the  neck.  This  case,  therefore,  is  an  additional  instance  of  partial  retro- 
venous  ]K)sition  of  the  gland. 

The  eai'lier  stages  of  development  of  the  thymus  sliow  very  clearly  how 
this  position  is  acquired.  Fig.  XXXIII  shows  tlie  anterior  view  of  the 
thoracic  contents  in  a  foetus  (//)  of  the  latter  part  of  the  fourtli  month. 
The  left  innominate  vein  (1)  passes  in  a  groove  along  the  upper  border  of 
the  thymus  gland.  The  cervical  portion  of  the  gland  has  not  yet  devel- 
o]>ed,  but  is  indicated  l)y  the  slightly  more  prominent  anterior  margin  of 
the  groove  containing  the  vein.  By  the  further  growth  of  this  portion  of 
the  gland  the  upper  segment  of  the  thymus  attains  its  usual  position  in 
front  of  the  vein. 

If  the  ])Osterior  border  of  the  groove  develops  at  the  same  time,  the 
retrovenous  ])rocess  (XXXII,  10)  results;  and  if  this  border  gives  rise  to 
the  entire  upper  segment  of  the  gland,  the  innominate  vein  will  course  in 
front  of  the  same,  at  the  junction  of  the  thoracic  and  cervical  portions. 

The  cer^^cal  j)ortion  is  very  varioush'  modified  by  the  different  form 
and  size  of  the  upper  processes  and  cornua,  which  frequently  reach  to  tlie 
lower  border  of  the  tlivroid  inland. 

In  the  usual  ai-rang<;ment,  the  more  flattened  cervical  j)ortion  is  se})a- 
ratc<l  when  liardened  in  situ  from  the  prismatic  thoracic  portion  by  a  con- 
strictif»n  or  neck  ])ro(hiced  on  each  side  l)y  an  obli(|ue  groove  in  wliich  tlie 
internal  niamnuiry  vessels  are  ])lacod  (Fig.  XXYII,  2). 

Kxplanation  of  Fi(jureH. 

(The  letters  refer  to  the  individuals,  indicating  the;  ])lates  taken  from 
the  same  fojtus.) 

Figs.  I  to  IV.  Right  and  left  lungs  of  fo-tus  of  2")  weeks  (estimated) 
{A\  m<*<li;il  and  lateral  surfa<'es. 

1.  i'ulmonary  attachment  of  br(jad  ligament. 

2.  Posterior  apical  costal  sulcus, 
•i.   Anterior  apical  costal  sulcus. 


Fiirs.  I  to  IV.  Tiig-lit  and  left  lungs  of  foetus  of  25  weeks  (estimated) 
(.Ij,  medial  and  lutoi-al  surfaces. 

1.  I'uhnonarv  attachment  of  broad  ligament. 
•_'.   Posterior  apical  costal  sulcus. 
■i.   Anterior  apical  costal  sulcus. 

4.  Anterior  marginal  fissure. 

5.  Secondary  fissure  of  cardiac  incisure. 


Fig.  I. 


Fig.  II, 


Fig.  III. 


Fig.  IV. 


Fi"-s.  \'  aiitl  \'l.  Outline  representations  of  the  l);isal  surfaces  of  the 
siinie  hin<is  (^1 1. 

1.   Sternocostal  surface. 
•J.  Antorio)'  margin. 
;l  ^lediastinal  surface. 

4.  Internal  niar<^in. 

5.  Costovertebral  surface. 
0.  Posterior  maroin. 

Fi<,^s.  \\\  to  X.  Ivi<^ht  and  left  lungs  of  foetus  of  31  weeks  (estimated) 
(B),  ni('<lia!  and  lateral   sui-faces. 


Fig.  V. 


Fig.  VI. 


Fig.  VII. 


Fig.  VIII. 


Figs.  \'II  to  X.     Right  and  left  lungs  of  Itjetus  of  31  weeks  (estimated) 
(/>'},  nu'dial  and  lateral  surfaces. 

1.  Pulniunarv  attachment  of  broad  ligament. 

2.  Posterioi'  aj^ical  costal  sulcus. 
.">.  Anterior  apical  costal  sulcus. 
4.  Anterior  marginal  fissure. 

Figs.  XI  and  XII.   Outline  representations  of  the  basal  surfaces  of  the 
same  lungs  {B). 

1.  Sternocostal  surface. 

2.  Antcrioi'  margin. 

3.  Mediastinal  surface. 

4.  Internal  margin. 

r>.  Costovci-tebral  surface, 
♦J.  Posterior  nuiririn. 


Fig.  IX. 


Fig.  X. 


Fig.  XI. 


Fig.  XII. 


Fig.  Xlll.  FcL'tus  at  tonn  iC).  liasal  view  of  hardened  lungs  and 
heart  removed  togetliei-  IVoni  thorax. 

1.  Portion  of  medial  margin  of  phrenic  surface  in  contact  with  right  side 
<if  a'so])hagus. 

"J.   IntVrioi'  vena  cava. 

3.  Portion  of  dia])hragm  attached  to  inferior  surface  of  pericardium. 

4.  (Esophageal  tuberosity  of  left  lower  lobe,  basal  surface. 

."..  Portion  of  medial  margin  of  phrenic  surface  in  contact  with  left 
side  of  oesoj)hagus. 

«V  Pliivnic  margin  of  aortal  surface. 

Fig.  XIV.  Fietus  at  term  (/>).     Left  lung.     Sternocostal  surface. 


Fig.  XIII. 


Fig.  XIV. 


Fig  XV.  Foetus  at  term  {D).     Left  lung.     jMediastinal  surface. 

1.  Pulinonai'v  attaclimeut  of  ligamentuin  latum. 

2.  Pericai'ilio-a^sopbageal  tuberosit}'. 

3.  Aortal  groove. 

4.  Subclavian  groove. 

5.  Presubclavian  area. 
0».  Thymic  surface. 

7.  Pericardial  surface. 

N.  Pericardial  surface  of  pericardio-oesophageal  tuberosity. 

*.♦.  CKsopliageal  surface  of  })ericardio-a'so])hageal  tuberosity. 

Fig.  XVI.   Fa-tus  at  term  {E).     Left  lung.     Sternocostal  surface. 


Fig.  XV. 


Fig.  XYI. 


Fiir.  XVII.   Foetus  at  term  {£").     ]\re(liastiiial  i3urface. 

1.  Pulmonary  attachment  of  ligamentum  latum. 

2.  Pericanlio-oesophageal  tuberosity. 

3.  Aortal  groove. 

4.  Suljclavian  groove. 

5.  PresuijclaWan  area. 
»j.  Thymic  surface. 

7.  Pericardial  surface. 

8.  Pericardial  surface  of  pericardio-oesophageal  tuberosity. 

9.  (Eso})hageal  surface  of  pericardio-oesophageal  tuberosity. 

Fig.    XVITa.      ScJHMiiatic  figure,   indicating    relations    of    mediastinal 
surface  of  left  lun''. 


Fig.  XVll. 


Aovta. 


; '// 


UtSt  ComYtvov  C».voti.clL   ^vtGv^.^ 

UC  ft     Pl^y-CKU   KfcYU^ 


lev  i,  c  A.V  cVCo - 


iH4    Rtttdi  0^   Riti  . 


Fig.  XVIIa. 


Fig.  X  VIII.      Foetus  at  term  (/>).     Anterior  view  of  lungs  and  medias- 
tinuiji  i/i  situ. 

1.  .Vnterioi"  surface  of  thoracic  portion  of  thymus  giand. 

'2.  Junction  of  riglit  suljchivian  and  internal  jugular  veins. 

y>.  liight  common  carotid  ai'tery. 

4.   Inferior  thyroid  vein. 

;"..  Siipei'ior  ]>i'evenous  cornu  of  thymus  gland. 

♦'..  Left  innominate  vein. 

7.  Left  subclavian  artery. 

8.  Parietal  jiericardium  divided  by  a  cruciform  incision. 

Fig.  XIX.     Foetus  at  term  (D).     Right  lung.     Sternocostal  surface. 


Fig.  XVIII. 


Fig.  XIX. 


Fig.  XX.     Foetus  at  term  (Z>).     Eight  lung'.     Mediastinal  surface. 
1.   Inferior  caval  surface. 
'2.   Pericardial  surface. 
."..  Tiiymic  surface. 

4.  Innuuiinatc  and  su]^erior  caval  surface. 

5.  Tracheal  and  upper  oesophageal  surface. 
•  >.  >vzvo:os  groove. 

7.  T.ower  a'so])hageal  surface. 

^.  I'ulnionarv  attachment   of  liganieiitum  latum. 

Fig.  XXI.     Foetus  at  term  (A').     Eight  lung.     Sternocostal  surface. 


Fig.  XX. 


Fig.  XXI. 


Fig.  XXII.     Fa?tus  at  term  {E).     liight  lung.     Mediastinal  surface. 
1.  Inferior  caval  surface. 
"1.  Pericaidial  surface. 

3.  Thymic  surface. 

4.  Innominate  and  superior  caval  surface. 

5.  Tracheal  and  upper  oesophageal  surface, 
•i.  Azvji'os  o-i'oove. 

7.  Lower  a*sophageal  surface. 
S.  Pulmonary  attachment  of  ligamcntum  latum. 

Fig.  XXIIa.     Schematic  figure  indicating  relations  of  mediastinal  sur- 
face of  riii'ht  luuii". 


Fig.   XXII. 


a^ni  Su.p«vCov  Vena.  C 4. vs. 


LVrvt  0^  RCciWC 


Tva.cf)C4.\  Soffajc?. 


Uppti-  Oe.sopil.4.cea.V 


1  ntivc  0  it  ».\  Vauv 
AzvaoS  Vein, 


S.ou)e.r. 
Oesop^doeil. 

Su.vFa.ci' 


Su.Yfa.ce  yov  O'rv.ftvmv  V4rv4.Cd.va.. 
Fig.  XXlIa. 


Fig.  XXIII.  Infant,  iinincdiately  after  l)irtli  (J^'').  Kight  lung. 
MiHliastinal  surfucv. 

1.  Inforit)!'  cava!  surface. 

2.  Pei'icardial  surface. 
'■'.  Thymic  surface. 

4.  Innominate  and  su})erior  caval  surface. 

;').  Tracliejil  and  upper  cesopliageal  surface. 

«5.  A/.ygos  groove. 

7.   L<)\\'er  cesopliageal  surface. 

s.   Pulmonary  attachment  of  ligamentum  latum. 

Fig.  XXIV.  F(X'tus  at  term  (/'/).  Plirenic  surface  of  i-iglit  lung,  with 
azygos  lissure  of  lower  lobe. 

1,  Azygos  lobule. 

.;.   .\/yg()s  fissnr(\ 

Fig.  XXA'.  Fd'tus  ut  term  {JJ).  i'lii'cnic  surface  of  right  lung,  with 
ay.ygos  fissure  of  lower  lobe. 

1.  A/.ygos  lissure. 


Fig.  XXIII. 


1     ■        -■  / 


Fig.  XXIV. 


Fig.  XXV. 


Fig.  XXN'I.  Fa'tiis  at  tenn  {D).  Mediastinal  contents,  left  lateral 
\\e\w  with  pariet^il  pleura  in  })lace. 

1.  Su]KM'ior  ])revenous  cornu  of  cervical  ])ortion  of  tliynins  gland. 

2.  Left  sul)clavian  artery,  supracostal  portion. 

3.  Left  sulx'lavian  vein. 

4.  Parietal  mediastinal  ]n'esul)clavian  surface,  covering  fatty  connec- 
tive anil  Ivnipliatic  tissue  overlying  left  common  carotid  artery,  behind 
thymus  and  left  innominate  veins. 

5.  Left  lateral  surface  of  tliymus  gland,  thoracic  ])ortion. 
»;.  Left  })hrenic  nerve. 

7.  Parietal  pericardium  divided. 

8.  Left  subclavian  artei'V,  ascending  ])ortion,  covered  by  parietal  pleura, 
y.  Left  sujierior  intercostal  vein,  covered  Ijy  parietal  pleura. 

10,  Oi)enings  at  hilus  of  divided  superior  left  pulmonary  veins. 
Between  1»>  and  11,  and  crossed  by  the  fork  at  10,  are  seen  the  openings 

of  the  divided  apical  branches  of  pulmonary  arter3^ 

11,  Pulmonary  artery,  divided  at  hilus. 

12,  V-^i.  Left  bronchus  (hyparterial)  divided  at  hilus. 

14.  Inferior  left  ])ulmonary  vein,  divided  at  hilus. 

15.  Tlxjracic  aorta  covered  by  ])arietal  pleura. 

1»*».  Left  surface  of  oesophagus  covered  by  parietal  pleura. 


Fig.  XXVI. 


Fig.  XX\'ll.     Infant  iiuiiiediately  after  l)irtli  (i^).      Mediastinal  con- 
tents, left  lateral  view ;  meiliastinal  ]x\rietal  pleura  partly  reflected, 

I.  Left  subclavian  vein. 

•J.   Left  internal  mammary  artery. 

:'>.   Fatty  connective  tissue  and  small  lym])liatic  glands  behind  left  in- 
nominate vein  and  thymus. 

4.  Left  lateral  (])leural)  surface  of  thymus  gland,  thoracic  portion. 
."».   Left  plu'enic  nerve. 

«;.   Left  subclavian  artery. 
7.  Left  deej)  cervical  vein. 

5.  Left  c(jmmon  carotid  artery. 
i>.  Left  vagus. 

lo.   rEso})hagus. 

II.  Left  suj)erior  intercostal  vein. 
12.  Left  pulmonary  artery. 

IM.   Suj)erior  left  pulmonary  vein. 

14.   Left  bronchus  (hyparterial)  cut  just  l)eyond  primary  division. 

lo.  Left  inferior  pulmonary  vein. 

10.  Thoracic  aorta,  covered  by  17,  parietal  pleura. 

18.  <^Kso])hagus,  covered  by  17,  parietal  pleura. 


__I8 


Fig.  XXVII. 


Fio:.  XXVI 1 1.      Fa?tus  at    term  (7f).      Mediastinal   contents.      Right 
lateral  view.      Parietal  pleura  in  ])laee. 

1.  Parietal  ])leiira  covering-  tracheal  and  su])eri()r  oesophageal  surfaces 
and  right  vagus. 

2.  Azygos  vein  at  junction  with  right  superior  intercostal  vein. 
8.   Right  syni})athetic  nerve. 

4.  Right  vagus,  inferior  oesophageal  branches. 
•">.   Right  subclavian  artery. 
«'•.  liight  subclavian  vein. 

7.  Left  innominate  vein. 

8.  Right  ])hrenic  nerve. 

0.  Right  lateral  (pleural)  surface  of  thymus  gland,  thoracic  ])ortion. 

10.  Superior  vena  cava. 

1 1.  A])ical  branch,  right  pulmonary  artery. 
ll^   lii^-ht  eparterial  bronchus. 

I-'!.   A]iical  branch  of  right  jndmonary  artery. 

14.  ]\Iain  trunk  of  I'ight  pulmonary  artery. 

15.  Itight  hyparterial  l)i'onchus. 

16.  Suj>erior  right  pulmonary  vein. 

17.  18.  Inferior  right  pulmonary  vein. 

T.t.  Tnfcrioi-  vena  cava,  intrathoracic  segment. 


Fig.  XXVIII. 


Fig.  XXIX.    Foetus  at  term  (D).    Mediastinal  contents  in  situ.     Right 
lateral  view,  u])])ei'  pai-t  of  mediastinal  ])lonr;i  reflected. 

I.  Vena  azyg(»s. 

'2.  Kight  subcla^^an  artery. 

.">.  Kiglit  sultclavian  vein,  cut  at  junction  with  riglit  internal  jugular. 

4.  (Esophagus. 

5.  Right  vagus. 
«■>.  Tracliea. 

7.  Fatty  connective  and  lym})hatic  gland  tissue  between  trachea  and 
right  innominate  vein. 

8,  Right  lateral  surface  of  thymus  gland,  thoracic  portion. 
0,  10.  .\.})ical  Ijranches  of  right  pulmonary  artery. 

II.  Riglit  bronchus,  cut  at  division    into    eparterial  and  hyparteriai 
trunks. 

l:i.  Right  ]ndmonary  artery. 

lo.  lii^lit  supei'ior  ))ulnionary  vein.  « 

14.  Right  inferi(jr  ])uhiionary  vein. 


Fig.  XXIX. 


Fig.  XXX.      Infant,  immediately  after  birth  [F").     Mediastinal  con- 
tents, right  lateral  view,  mediastinal  parietal  pleura  reflected. 

I.  (Esophagus. 

'2.   Right  vertebral  veiu. 

l^.  Trachea. 

4.  .Vyzgos  vein. 

o.  Left  parietal  ]>leura,  costovertebral  division. 

♦;.  Tliorac-ic  aorta. 

7.  llenuazygos  vein. 

8.  liiglit  vertebral  arter3^ 
'.».   Uiglit  subclavian  artery, 
lo.  liight  subclavian  vein. 

II.  Scalenus  anticus,  cut. 

12.  Iliglit  internal  mammary  artery. 

\'-'>.  Peritracheal  fatty  connective  and  lym]ihatic  tissue. 

l-t.  Itight  vagus. 

15.  Superior  cava. 

10.  liight  phrenic  nerve. 

17.  liight  e})arterial  bronchus. 

IS,  19.  Apical  branches  riglit  jiubiioiiai-y  artery. 

20.  liiglit  hyparterial  bronchus. 

21.  liight  suj)erior  ])ulmonar\^  vein. 

22.  iMain  trunk  right  pulmonary  artery. 
•2'^.   Right  inferior  pulmonary  vein. 

24.   Inferior  vena  cava. 


— 1i^ 


Fig.  XXX. 


Fi«jr.  XXXI.      Fci'tus  at  torni  {E).     Anterior  view  of  thoracic  viscera. 

I.  Junction  of  right  jugular  and  subclavian  veins. 
•2.   First  ril).  divided. 

."5.    liiglit  })arietal  pleura,  anterior  portion  of  sternocostal  division. 

4.  IVricardiuin,  portion   uncovered   by    })leura    and   exposed   between 
right  and  left  mediastinal  pleural  reflections. 

5.  Left  internal  jugular  vein. 
•'..    Left  external  jugular  vein. 

7.   Anterior  surface  thymus  gland,  cci'vical  ]V)rtion. 

S.   Left  subclavian  vein. 

1».   Left  innominate  vein. 

lo.   ^\nt<'i-ioi'  surface  thymus  glaird,  thoracic  portion. 

II.  Right    mediastinal   ])leura,    passing  to  lateral  surface  of    thymus 
gland. 


Fig.  XXXI. 


FiiT.  XXXll.  I'u'tns  at  tt'ini  (^/>).  Lungs  and  uu'diastinal  contents, 
vii'wed  from  above. 

I.  (Est»phagiis. 
•_>.  Trachea. 

.).   Kiirlit  sul)clavian  arterv. 

4.  liight  innominate  vein. 

."►.    liiirlit  internal  niamniai-v  arterv. 

♦;.   Anteiior  surface  right  ventricle,  parietal  pericardium,  cut. 

7.  J^eft  common  carotid  arterv. 

5.  Left  innominate  vein. 
'.».   Left  subclavian  ai'tcry. 

lo.   Superior  retrovenous  cornu  of  thymus  gland. 

I I.  Ascending  aorta. 

1 L' .    I  'uhnonar V  arterv. 

i;!.   Pericardium,  divided. 

14.    Right  auricular  appendix. 

l."».  Superior  prevenous  cornu  of  thymus  gland,  cervical  ])0)'tion  turned 
forward  and  downward. 

Fig.  XXXIIL  Foetus  of  fourth  month  (//).  Anterior  view  of 
thoracic  viscera. 

1.  Left  innominate  vein. 

Fiir.  XXXIV.  Schematic  transection  of  thorax  below  level  of  pul- 
nionary  hilus,  to  show  pleural  reflection  forming  the  broad  pulmonary 
ligament  (viewed  from  above). 

1.   Thoracic  aorta. 

li.  'Ksophagns.  • 

'4.   Left  in-oad  ligament. 

4.    i'ei'icai'ijiiiiii. 

.'».   ]^_'l•ica^dial  division  <»!'  mediastinal  ])leui'a. 

(').  Pericartliiiiii. 

7.    \'isce)-al  ]»lenra.  mediastinal  sui-face. 

^.  J'arietal  j)leura,  sternocostal  division. 

!♦.  Inferior  vena  cava. 

1".   Right  b)'oad  ligament. 

1  \.  >\/.ygos  vein. 


Fig.  XXXII. 


Fig.  XXXIII. 


Fig.  XXXIV. 


ANATOMY    OF   THE   THORAX    IN   THE    FOETUS   AT   TERM,    ETC.  345 

4.  Anterior  marginal  fissure. 

5.  Secondary  fissure  of  cardiac  incisure. 

Figs,  Y  and  YI.  Outline  representations  of  the  basal  surfaces  of  the 
same  lungs  (A). 

1.  Sternocostal  surface. 

2.  Anterior  margin. 

3.  Mediastinal  surface. 

4.  Internal  margin. 

5.  Costovertebral  surface. 

6.  Posterior  margin. 

Figs.  YII  to  X.  Eight  and  left  lungs  of  foetus  of  31  weeks  (estimated) 
(B),  medial  and  lateral  surfaces. 

1.  Pulmonary  attachment  of  broad  ligament. 

2.  Posterior  apical  costal  sulcus. 

3.  Anterior  apical  costal  sulcus. 

4.  Anterior  marginal  fissure. 

Figs.  XI  and  XII.   Outline  representations  of  the  basal  surfaces  of  the 
same  lungs  (B). 

1.  Sterno-costal  surface. 

2.  Anterior  margin. 

3.  Mediastinal  surface. 

4.  Internal  margin. 

5.  Costovertebral  surface. 

6.  Posterior  margin. 

Fig.  XIII.  Foetus  at  term  {C).      Basal  view  of   hardened  lungs  and 
heart  removed  together  from  thorax. 

1.  Portion  of  medial  margin  of  phrenic  surface  in  contact  with  right  side 
of  oesophagus. 

2.  Inferior  vena  cava. 

3.  Portion  of  diaphragm  attached  to  inferior  surface  of  pericardium. 

4.  CEsophageal  tuberosity  of  left  lower  lobe,  basal  surface. 

5.  Portion  of  medial  margin  of  phrenic  surface  in  contact  with  left 
side  of  oesophagus. 

6.  Phrenic  margin  of  aortal  surface. 

Fig.  XI Y.  Foetus  at  term  (Z>).     Left  lung.     Sternocostal  surface. 
Fig  XY.  Foetus  at  term  {B).     Left  lung.     Mediastinal  surface. 

1.  Pulmonary  attachment  of  ligamentum  latmn. 

2.  Pericardio-oesophageal  tuberosity. 

3.  Aortal  groove. 

4.  Subclavian  groove. 

5.  Presubclavian  area. 

6.  Thymic  surface. 

7.  Pericardial  surface. 

8.  Pericardial  surface  of  pericardio-oesophageal  tuberosity. 

9.  CEsophageal  surface  of  pericardio-oesophageal  tuberosity. 

Fig.  XYL  Foetus  at  term  (^).     Left  lung.     Sternocostal  surface. 
Fig.  XYII.  Foetus  at  term  (B).     Mediastinal  surface. 


oiO  REPORT   OF  THE   SOCIETY   OF   THE   LYING-IX   HOSPITAL. 

1.  Pulnionarv  attachment  of  lifjamentimi  latum. 


>.) 


Fericardio-a?sophageal  tuberosity. 


3.  Aortiil  groove. 

4.  Subclavian  groove. 

5.  Presubclavian  area. 
(').  Thymic  surface. 

7.  Pericarilial  surface. 

8.  Pericarilial  surface  of  pericardio-o?soi)liageal  tuberosity. 

0.  (£soj)hageal  surface  of  i)ericardio-a^so|")hageal  tuberosity. 

Fig.  XVIIa.  Schematic  figure,  indicating  relations  of  mediastinal 
surface  of  left  lung. 

Fig.  XVIII.  Foetus  at  term  (D).  Anterior  view  of  lungs  and  medias- 
tinum hi  sitv. 

1.  Anterior  surface  of  tlioracic  portion  of  thymus  gland. 

2.  Junction  of  right  subclavian  and  internal  jugular  veins. 

3.  Right  common  carotid  artery. 

4.  Inferior  thyroid  vein. 

5.  Superior  prevenous  cornu  of  thymus  gland. 

6.  Left  innominate  vein. 

7.  Left  subclavian  artery. 

8.  Parietal  pericardium  divided  b}^  a  cruciform  incision. 

Fig.  XIX.     Foetus  at  term  (D).     Right  lung.     Sternocostal  surface. 
Fig.  XX.     Foetus  at  term  (D).     Right  lung.     Mediastinal  surface. 

1.  Inferior  caval  surface. 

2.  Pericardial  surface. 

3.  Thymic  surface. 

4.  Innominate  and  superior  caval  surface. 
.5.  Tracheal  and  upper  oesophageal  surface. 

6.  Azygos  groove. 

7.  Lower  (x;so|)liageal  surface. 

8.  Pulmonary  attaclnnent   of  ligamentum  latum. 

Fig.  XXI.     Foetus  at  term  (E).     Riglit  lung.     Sternocostal  surface. 
Fig.  XXII.     Ffjetus  at  term  (^).     Right  lung.     Mediastinal  surface. 

1.  Inferior  caval  surface. 

2.  Pericardial  surface. 

3.  Thymic  surface. 

4.  Innominate  and  superior  caval  surface. 
.5.  Tracheal  and  upper  oesophageal  surface. 
♦"».  Azvgos  groove. 

7.  I..ower  (jL*soi)hageal  surface. 

8.  Pulmonary  attachment  of  ligamentum  latum. 

I'ig.  XXIIa.  Schematic  figure  indicating  relations  of  mediastinal  sur- 
face of  right  lung. 

Fig.  XX HI.  Infant,  immediately  after  birth  (7''').  Right  lung. 
Me<li;ustina]  surface. 

1.  Inferior  caval  surface. 

2.  Pericardial  surface. 


ANATOMY   OF   THE    THORAX    IN   THE    FCETUS   AT   TERM,    ETC.  347 

3.  Thymic  surface. 

4.  Innominate  and  superior  caval  surface. 

5.  Tracheal  and  upper  oesophageal  surface. 

6.  Azygos  groove. 

7.  Lower  oesophageal  surface. 

8.  Pulmonary  attachment  of  ligamentum  latum. 

Fig.  XXIV.  Foetus  at  term  (G).  Phrenic  surface  of  right  lung,  with 
azygos  fissure  of  lower  lobe. 

1.  Azygos  lobule. 

2.  Azygos  fissure. 

Fig.  XXV.  Foetus  at  term  (Z>).  Phrenic  surface  of  right  lung,  with 
azygos  fissure  of  lower  lobe. 

1.  Azygos  fissure. 

Fig.  XXVI.  Foetus  at  term  (D).  Mediastinal  contents,  left  lateral 
view,  with  parietal  pleura  in  place. 

1.  Superior  prevenous  cornu  of  cervical  portion  of  thymus  gland. 

2.  Left  subclavian  artery,  supracostal  portion. 

3.  Left  subclavian  vein. 

4.  Parietal  mediastinal  presubclavian  surface,  covering  fatty  connec- 
tive and  lymphatic  tissue  overlying  left  common  carotid  artery,  behind 
thymus  and  left  innominate  veins. 

5.  Left  lateral  surface  of  thymus  gland,  thoracic  portion. 

6.  Left  phrenic  nerve. 

7.  Parietal  pericardimn  divided. 

8.  Left  subclavian  artery,  ascending  portion,  covered  by  parietal  pleura. 

9.  Left  superior  intercostal  vein,  covered  by  parietal  pleura. 

10.  Openings  at  hilus  of  divided  superior  left  pulmonary  veins. 
Between  10  and  11,  and  crossed  by  the  fork  at  10,  are  seen  the  openings 

of  the  divided  apical  branches  of  pulmonary  artery. 

11.  Pulmonary  artery,  divided  at  hilus. 

12.  13.  Left  bronchus  (hyparterial)  divided  at  hilus. 

14.  Inferior  left  pulmonary  vein,  divided  at  hilus. 

15.  Thoracic  aorta  covered  by  parietal  pleura. 

16.  Left  surface  of  oesophagus  covered  by  parietal  pleura. 

Fig.  XXVII.  Infant  immediately  after  birth  (i^).  Mediastinal  con- 
tents, left  lateral  view ;  mediastinal  parietal  pleura  partly  reflected. 

1.  Left  subclavian  vein. 

2.  Left  internal  mammary  artery. 

3.  Fatty  connective  tissue  and  small  lymphatic  glands  behind  left  in- 
nominate vein  and  thymus. 

4.  Left  lateral  (pleural)  surface  of  thymus  gland,  thoracic  portion. 

5.  Left  phrenic  nerve. 

6.  Left  subclavian  artery. 

7.  Left  deep  cervical  vein. 

8.  Left  common  carotid  artery. 

9.  Left  vagus. 

10.  (Esophagus. 


348  REPORT   OF   THE    SOCIETY    OF   THE    LYING-IX    HOSPITAL, 

11.  Left  su}>erior  intercostal  vein. 

12.  Left  pulinonarv  artorv. 

13.  Sui>erior  left  piilmonarv  vein. 

14.  Left  bronchus  (^liyparterial)  cut  jnst  beyond  primary  division. 

15.  Left  inferior  pulmonary  vein. 

16.  Thoracic  aorta,  covered  by  17,  parietal  })leura. 
IS.  (Eso])hagus,  covered  by  17.  parietal  pleura. 

Fi"-.  XXVIIL      Fa^tus  at   term  {E).      Mediastinal   contents.       Right 
lateral  view.     Parietal  pleura  in  place. 

I .  Parietal  pleura  covering  tracheal  and  superior  oesophageal  surfaces 
and  right  v;igus. 

'2.  Azvgos  vein  at  junction  Avith  right  superior  intercostal  vein. 
8.   Right  sympathetic  nerve. 

4.  Right  vagus,  inferior  oesophageal  branches. 

5.  Right  subclavian  artery. 
«;.  Right  subchivian  vein. 

7.  Left  innominate  vein. 

8.  Right  ])hrenic  nerve. 

9.  Right  lateral  (pleural)  surface  of  thymus  gland,  thoracic  portion. 

10.  Superior  vena  cava. 

II.  A]>ical  branch,  right  pulmonary  artery. 

12.  Right  eparterial  bronchus. 

13.  Apical  branch  of  right  pubnonary  artery. 

14.  Main  trunk  of  right  ])ulmonary  artery. 

15.  Right  hyparterial  bronchus. 

16.  Su])erior  right  pulmonary  vein. 

17.  IS.  Inferior  right  pulmonary  vein. 

19.  Inferior  vena  cava,  intrathoracic  segment. 

Fig.  XXIX.    Foetus  at  term  (J)).    Mediastinal  contents  m  situ.     Right 
lateral  view,  upper  part  of  mediastinal  pleura  reflected. 

1.  Vena  azygos. 

2.  Riffht  subclavian  arterv. 

3.  Right  subclavian  vein,  cut  at  junction  with  right  internal  jugular. 

4.  (T]sophagus. 

5.  Right  vagus. 

6.  Trachea. 

7.  Fatty  connective  and   lyiii])1iati('  gland   tissue  between  trachea  and 
right  innominate  vein. 

8.  Right  lateral  surface  of  thymus  gland,  thoracic  portion, 
f'.  lo.   A|»ir;d  bi-unches  of  right  pulmonary  artery. 

11.  liiglit  bronchus,  cut  at  division    into    eparterial   and   hyparterial 
trunks. 

12.  Right  ])ulniOnarv  artery. 

13.  Right  superioi"  j)ulmonary  vein. 

14.  Rifrht  inferior  pulmonary  vein. 

Fig.  X.XX.       Infant,   inimediately  after  birth   (/•').      Mediastinal  con- 
tents, riglit  lateral  view,  mediastinal  parietal  ])h'ura  rcllected. 


ANATOMY    OF   THE   THORAX    IN   THE   FCETUS   AT   TERM,    ETC.  349 

1.  Qi^sopliagiis. 

2.  Right  vertebral  vein. 

3.  Trachea. 

4.  Ayzgos  vein. 

5.  Left  parietal  pleura,  costovertebral  division. 

6.  Thoracic  aorta, 

7.  Hemiazygos  vein. 

8.  Right  vertebral  artery. 

9.  Right  subclavian  artery. 

10.  Right  subclavian  vein. 

11.  Scalenus  anticus,  cut. 

12.  Right  internal  mammary  artery. 

13.  Peritracheal  fatty  connective  and  lymphatic  tissue. 

14.  Right  vagus. 

15.  Superior  cava. 

16.  Right  phrenic  nerve. 

17.  Right  eparterial  bronchus. 

18.  19.  Apical  branches  right  pulmonary  artery. 

20.  Right  hyparterial  bronchus. 

21.  Right  superior  pulmonary  vein. 

22.  Maiu  trunk  right  pulmonary  artery. 

23.  Right  inferior  pulmonary  vein. 

24.  Inferior  vena  cava. 

Fig.  XXXI.     Foetus  at  term  (E).     Anterior  view  of  thoracic  viscera. 

1.  Junction  of  right  jugular  and  subclavian  veins. 

2.  First  rib,  divided. 

3.  Right  parietal  pleura,  anterior  portion  of  sternocostal  division. 

4.  Pericardium,  portion   uncovered   by   pleura   and   exposed   between 
right  and  left  mediastinal  pleural  reflections. 

5.  Left  internal  jugular  vein. 

6.  Left  external  jugular  vein. 

7.  Anterior  surface  thymus  gland,  cervical  portion. 

8.  Left  subclavian  vein. 

9.  Left  innominate  vein. 

10.  Anterior  surface  thymus  gland,  thoracic  portion. 

11.  Right   mediastinal  pleura,   passing  to  lateral  surface  of    thymus 
gland. 

Fig.  XXXII.     Foetus  at  term  (i>).     Lungs  and  mediastinal  contents, 
viewed  from  above. 

1.  (Esophagus. 

2.  Trachea. 

3.  Right  subclavian  artery. 

4.  Right  innominate  vein. 

5.  Right  internal  mammary  artery. 

6.  Anterior  surface  right  ventricle,  parietal  pericardium,  cut. 

7.  Left  common  carotid  artery. 

8.  Left  innominate  vein. 


350  REPORT   OF   THE   SOCIETY    OF   THE    LYING  IN    HOSPITAL. 

9.  Left  subclavian  artery. 

10.  Superior  retrovenous  cornu  of  thymus  giaud. 

11.  Asceiulini^-  aorta. 

12.  Puliuonai'v  artery. 

13.  Pericardium,  divided. 

14.  Right  auricuhir  ai)})eutlix. 

15.  Superior  prevenous  cornu  of  thymus  gland,  cervical  portion  turned 
forwaixl  and  downward. 

Fig.  XXXIIl.  Fcvtus  of  fourth  month  (//).  Anterior  view  of 
thoracic  viscera. 

1.  Left  innominate  vein. 

Fig.  XXXR'.  Schematic  transection  of  thorax  below  level  of  pul- 
monary hilus,  to  show  pleural  reflection  forming  the  broad  pulmonary 
ligament  (Anewed  from  above). 

1.  Thoracic  aorta. 

2.  (Esophagus. 

3.  Left  broad  ligament. 

4.  Pericardium. 

5.  Pericardial  division  of  mediastinal  pleura. 
(!.  Pericardium. 

7.  Visceral  ]ileura,  mediastinal  surface. 

8.  Parietal  pleura,  sternocostal  division. 

9.  Inferior  vena  cava. 

10.  Eight  broad  ligament. 

11.  Azygos  vein. 


EEPORT   OF   PATHOLOGIST. 
By  Farquhar  Ferguson,  M.D. 


The  following  is  a  statement  of  the  work  clone  in  the  pathological 
department  of  the  Hospital  during  the  year  ending  January  1,  1897: 

There  have  been  only  three  autopsies  on  women  dying  after  childbirth. 
In  two  of  these  the  cause  of  death  was  due  to  septic  peritonitis,  and  in  each 
of  these  cases  the  streptococcus  pyogenes  was  found  in  the  uterus,  in  the 
Fallopian  tubes,  and  in  the  purulent  fluid  in  the  peritoneum.  The  third  case 
revealed  a  gastric  ulcer  and  enormous  abscesses  in  the  liver,  which  were 
directly  connected  with  the  ulcer.  The  staphylococcus  pyogenes  aureus 
and  albus  were  obtained  in  cultures  made  at  the  postmortem  in  this  case. 

Twenty  autopsies  were  made  on  infants,  most  of  them  by  Dr.  Martha 
Wollstein,  Assistant  Curator.  The  majority  of  these  were  abortions  and 
still-born,  and  as  the  remainder  died  shortly  after  birth,  there  was  no 
notable  lesion  in  any  of  the  cases  to  account  for  death. 


REPORT   OF  BACTERIOLOGIST. 
By  Martha  Wollstein,  M.D. 


Bacteriological  examinations  of  vaginal  and  uterine  secretions  have 
been  made  in  twenty-four  cases,  of  which  four  were  fuU  term,  three  prema- 
ture, and  seventeen  abortions.  Cultures  in  glycerine  agar  were  taken  from 
the  up})er  part  of  the  vagina  and  from  the  uterine  cavity  before  operative 
interference,  after  operation,  and,  in  some  cases,  at  the  end  of  the  puerpe- 
liuni.     Tlie  results  are  tabulated  below. 

I.    Full  Term. 


C.  N. 


7,018 

7,808 

9.959 
738 


Uterus. 


Before  Operation. 


Staph,  pyog.  aureus 


((        (( 


"       alb.  . 
No  culture  taken . 


After  Operation. 


Staph,  pyog.  aureus 

"      albus. 
Sterile  


Vagina. 


Before  Operation. 


j  Tube  broken } 
\     when  rec'd.     ( 
C  Staph,   pyoj 
<    alb.  ;    stapl 
I    pyog.  aur. 
No  culture  taken . 


After  Operation. 


No  culture  taken. 

\  Staph,  pyog.  alb. 
(      "  "      aur. 

No  culture. 
Staph,  aureus. 


In  C.  X.  7,018,  cultures  from  the  pus  of  an  abscess  over  the  left  deltoid 
region  showed  a  growth  of  staphylococcus  aureus  and  streptococcus  pyogenes 
longus. 

It  is  interesting  to  note  that  cases  7,018  and  7,808  ran  a  febrile  tempera- 
ture, while  9,959  did  not;  and  in  738  the  fever  was  attributed  to  another 
cause  than  uterine  infection. 

II.    Premature. 


C   N 

Uterus. 

Vagina. 

Before  Operation. 

After  Operation. 

Before  Operation. 

After  Operation. 

6,880 
7,167 

Sterile  

No  culture  taken. . 

No  culture  taken. 

1 1 

Sterile 

(Staph,    pyog.  ) 
J    alb. ;    bacillus  r 
(    coli  com.           ) 
No  culture  taken . . 

Staph,  pyog.  albus. 
No  culture  taken. 

51 

,j 

REPORT   OF   BACTERIOLOGIST. 


353 


A  Petri  dish  containing  agar  was  exposed  to  the  air  in  the  room  of 
patient  No.  7,16Y  for  forty-eight  minutes;  the  following  micro-organisms 
developed  colonies:  sarcina  aurantica,  staphylococcus  pyogenes  albus, 
bacillus  subtilis,  bacillus  fluorescens  liquefaciens,  and  aspergillus  niger. 


III.    Abortions. 


C   N 

Uterus. 

Vagina. 

Before  Operation. 

After  Operation. 

Before  Operation. 

After  Operation. 

6,909 
6  891 

Sterile 

Sterile 

Staph,  pyog.  albus 
C  Bacillus    coli  ) 
'    com.  Bacillus  > 
/    fiuor.  non-liq.  ) 

Sterile 

Sterile 

u 

No  culture  taken 

7,022 
7,029 

7,117 
7  177 

u 

Sterile 

u 

f  Strepto.  brevis.  ] 

1    Diplococcus 

subflavus  of  r 

Bumm.             J 

(  Diplococcus  al-  J 

-<    bicans    of>- 
(    Bumm.              ) 

Broken  when  rec'd 

Red  yeast 

i  Bacillus    coli  | 
<    com.      Staph.  >- 
(    pyog.  aureus.  ) 

Sterile 

No  culture  taken 

u 

No  culture  taken. . 

Sterile 

(1 

(C 

u 

No  culture  taken . . 
Sterile 

No  culture  taken . . 

((                  ((                    u 

j  Atendofpuerp.:  ) 
\    sterile.               ( 

No  culture  taken . . 

Sterile 

"             ((              u 

u 

sterile 

7  211 

(( 

No  culture  taken 

7,465 

u 

Sterile. 

7,683 
8  086 

u 

i  i 

u 

Bacillus  coli  com . . 
Staph,  pyog.  albus. 
Staph,  pyog.  albus. 
No  culture  taken . . 

U                  ((                    u 
U                 ((                   u 

Tube  broken 

( Staph,     albus.  ) 
<    Bacillus    coli  >■ 
(    communis.       ) 

No  culture  taken 

8,077 
8,087 
6  880 

u 

Staph,  pyog.  albus. 
No  culture  taken 

u 

(( 

((                  ((                    u 

6,855 

6,915 
6,924 

No  culture  taken . . 

U                   U                      11 

sterile 

\  At  end  of  puerp. : 
\  staph,  pyog.  alb. 
S  At  end  of  puerp.  : 
I  staph,  pyog.  alb. 
Sterile. 

7,034 

u 

(( 

Bacillus  coli  com. 

Petri  plate  (agar)  exposed  to  the  air  for  one  hour  in  the  room  of  patient 
Y,211  developed  colonies  of  sarcina  lutea,  staphylococcus  albus,  bacillus 
subtilis,  bacillus  fluorescens  liquefaciens,  red  yeast,  and  penicillium  glaucum. 

Surgical  dressings  have  been  examined  on  three  occasions.  The  method 
employed  was  the  same  throughout:  pieces  were  snipped  off  from  various 
portions  of  each  article  by  means  of  scissors  and  forceps  sterilized  by  dry 
heat,  and  the  pieces  dropped  into  sets  of  bouillon,  agar,  and  gelatine  tubes. 
The  bouillon  and  agar  tubes  were  placed  in  the  thermostat  and  examined  at 
the  end  of  twenty-four  hours.  If  sterile,  the  tubes  were  examined  daily 
for  ten  to  fourteen  days.  The  gelatine  tubes  were  kept  at  the  room  tem- 
perature. 

23 


tine,  or  bouillon. 


354  REPORT   OF   THE   SOCIETY   OF  THE   LVIXG-IX   HOSPITAL. 

I.  March  14,  1895. 
Cotton  wipes  in  tins. 
Vulva  pads  in  tins. 
Soft  catheter  in  5  per  cent,  carbolic  acid,      I   No  growth  on  agar,  gela- 
Sterilized  gauze  in  Kelly  tube. 
Iodoform  gauze  in  Kelly  tube, 
Starch  ])owder  in  glass  bottle, 
Tape  (for  ct)rd)  in  glass — growth  of  bacillus  coli  communis. 

Dry  wipes  in  glass  bottle — growth  of  staphylococcus  ]3yogenes  albus. 
Eye  wipes  in  boracic   acid — growth  of  an  unidentified   bacillus,  non- 
pathogenic. 

II.  March  30,  1896. 

Dry  wipes  in  glass  bottle — growth  of  bacillus  subtilis  and  staphylococcus 
albus. 

Cord  tape  in  glass— growth  of  saccharomyces  and  staphylococcus  albus. 

Nail  brush — sterile. 

The  result  of  the  culture  from  the  nail  brush  was  sufficiently  surprising 
to  warrant  a  second  experiment. 

A  well-used  brush  w^as  taken  from  labor  bag  No.  18,  which  was  on  the 
slielf  ready  for  service.  "With  a  pair  of  sterilized  scissors  a  number  of 
bristles  were  cut  off  and  dropped  into  some  bouillon,  agar,  and  gelatine 
tubes,  the  brush  being  held  directly  over  the  mouth  of  the  tubes.  A  second 
set  of  tubes  were  inoculated  with  •  scrapings  made  with  a  stiff  platinum 
neeiUe  all  over  the  wood  of  the  brush,  between  the  bristles.  No  growth 
of  any  kind  appeared  in  any  one  of  the  twelve  tubes  inoculated. 

The  conclusion  is  obvious,  then,  that  such  a  brush  in  daily  use  becomes 
sufficiently  saturated  with  the  bichloride  of  mercury  solution  used  in  scrub- 
bing the  hands  as  to  hold  no  viable  bacteria  upon  or  between  its  bristles. 
I^ss  than  twenty-four  hours  had  elapsed  between  the  use  of  the  brush  and 
the  making  of  the  cultures. 

III.  Septemler  11,  1896. 

All  the  contents  of  labor  bag  No.  5  (ready  for  use)  were  tested: 

Glass  catheter,  in  glass  tul>e,  ])repared  by  steaming  half  an  hour,  at  240 
degrees  Fahrenheit — no  growth. 

Intrauterine  tube,  in  glass  tube,  prepared  by  steaming  half  an  hour,  at 
240  degre«'s  Fahrenheit — no  growth. 

Nail  brush — no  growth. 

Vulva  pad,  in  tin,  steamed  half  an  hour — no  growth. 

C(jtton,  in  tin,  steamed  half  an  hour — no  growth. 

Solution  of  silver  nitrate  (1  per  cent.) — no  growth. 

Eye  dro]>|x.'r,  carried  free  in  kxip  on  under  surface  of  cover  of  bag — 
staphylocfK'cus  aureus. 

Eye  wijies,  in  saturated  boracic  solution — bacillus  coli  communis;  peni- 
cillium  gjaucum. 

\)vy  wijies,  in  bottle,  not  steamed — staphylococcus  cereus  llavus. 


REPORT    OF    BACTERIOLOGIST. 


355 


Cord  tapes,  not  steamed — bacillus  coli  communis. 

Starch,  powdered,  in  bottle — bacillus  megaterium. 

Rubber  pad  (Kelly),  scrubbed  and  carbolized — bacillus  coli  communis; 
sta]")hylococcus  aureus. 

Cultures  were  made  from  the  hands  of  four  internes  who  had  ])repared 
themselves  in  the  usual  way  (scrubbing  with  green  soaj),  bichloride,  and 
rinsing  with  distilled  water)  for  the  examination  of  a  patient.  Scrapings 
were  taken  from  underneath  and  about  the  nails. 


Ko. 

Right  Hand. 

Left  Hand. 

1 

9, 

Staphylococcus  pyogenes  albus  .  . . 
Sterile 

Staphylococcus  pyogenes  albus. 
"                cereus  flavus. 

3 
4 

j  Staphylococcus  pyogenes  albus.  ) 
(             "                "    "     citreus.  \ 
j  Staphylococcus    pyogenes    al-  \ 
\      bus  ;  penicillium  glaucum.      \ 

"                pyogenes  albus. 

Eyes  of  babies  with  purulent  conjunctivitis  were  examined  by  cultures 
and  cover  slips  in  four  cases: 

Gonococci  were  found  in  two,  C.  N.  13  and  716. 
Staphylococci  (aureus)  found  in  one,  C.  I^.  223. 
Pseudo-diphtheria  bacillus  found  in  one,  C.  IST.  721. 

Throat  cultures  were  taken  from  two  cases : 

Staphylococcus  pyogenes  aureus  and  streptococcus  pyogenes;  no  Klebs- 
Loffler  baciUi  in  either  C.  IT.  10,518  or  C.  E".  738. 

Sptttum  from  C.  N.  225  was  found  negative  for  tubercle  bacilli. 

Pus  from  abscess  on  hip  of  baby  (A,  N.  14,605)  negative  for  tubercle 
bacilli;  cultures  show  a  growth  of  staphylococci  and  streptococci. 


1 

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